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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/bonegraftsurgeryOOalbe 


BONE-GRAFT 
SURGERY 


BY 

FRED  H.  ALBEE,  A.  B.,  M.  D..  F  A.  C.  S. 

Professor  of  Orthopedic  Surgery  at  the  New  York  Post-Graduate 
Medical  School  and  the  University  of  Vermont;  Visiting  Orthopedic 
Surgeon  to  the  Xew  York  Post-Graduate  Hospital  and  Blythedale 
Hospital;  Consulting  Orthopedic  Surgeon  to  the  Mary  Fletcher  Hos- 
pital, Burlington,  Vermont,  Sea  View  Hospital,  New  York,  Muhlen- 
burg  Hospital,  Plainfield,  New  Jersey,  German  Hospital,  Newark, 
New  Jersey,  and  Waterbury  Hospital,  Waterbury,  Conn.;  Member 
of  the  American  Orthopedic  Association;  Corresponding  Member  of 
the    German    Orthopedic    Association,    Etc. 


WITH   332    ILLUSTRATIONS 
THREE  OF  THEM  IN  COLORS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1915 


/// 
^  /■ 

/9/r 


Copyright,  1915,  by  W.  B.  Saunders  Company 


Prinled  in  America 


THIS  BOOK  IS  DEDICATED 

TO  THE 

PROGRESS  OF  SURGERY 

OF  THE 

BONES  AND  JOINTS 


PREFACE 


The  author  has  been  induced  to  write  this  book  in  order  to 
answer  as  far  as  possible  the  many  inquiries  in  regard  to  bone 
grafting  and  to  present  the  technique  of  the  apphcation  of  the 
bone  graft  in  the  widening  field  for  its  use,  which  is  covered  in  no 
other  work  yet  published.  The  greater  portion  of  this  book 
presents  the  author's  original  applied  technique  with  ample 
illustrations. 

Bone,  being  one  of  the  simple  connective  tissues,  lends  itself 
favorably  to  transplantation  and  to  the  repair  of  skeletal  de- 
ficiencies and  is  the  most  reliable  means  of  internal  bone  fixa- 
tion. Instead  of  antagonizing  Nature  by  attempting  to  intro- 
duce a  foreign  substance,  the  surgeon,  by  using  autogenous 
material  is  following  Nature's  own  method,  being  thereby  able 
to  overcome  mechanical  surgical  defects  which  he  has  hitherto 
been  unable  to  cope  with.  The  use  of  uncertain  extemporizing 
methods  and  the  application  of  external  fixation  braces  cannot 
compare  with  the  accurate,  direct  internal  implantation  of  an 
autogenous  bone  graft  contacting  corresponding  structures  of 
graft  and  host  bone,  i.e.,  periosteum  to  periosteum,  compact  bone 
to  compact  bone,  endosteum  to  endosteum  and  marrow  to 
marrow. 

As  improved  machinery  and  tools  have  made  the  skilled 
artisan  more  efficient,  so  likewise  has  the  introduction  of  ront- 
genography  and  electrically  driven  tools  augmented  the  skill 
and  accuracy  of  the  surgeon  in  arresting  bone  diseases  and  re- 
storing bone  defects  and  has  opened  ways  of  dealing  with  bone 
and  joint  conditions  such  as  have  never  been  attempted  with 
the  cruder  hand  tools.  Though  the  author  considers  the  use 
of  the  motor-driven  tools  as  more  nearly  approaching  the  ideal 
conditions  yet  there  are  instances  where  their  use  is  not  abso- 
lutely essential. 

13 


14  PREFACE 

Bone  and  joint  work  is  a  difliciilt  surji;i('al  specialty,  involving 
^pjt.ionly  the  surgical  management  of  soft  tissues  but  bone  tissue 
as  well.  The  successful  outcome  of  any  procedure  to  restore 
the  skeletal  architecture  depends  not  only  upon  a  proper  opera- 
tive techni(iue  but  in  many  cases  in  a  greater  degree  upon  the  skill 
with  which  the  post-oix^-ative  external  fixation  dressing  is  ap- 
plied and  in  the  convalescent  management  of  the  case. 

The  author  wishes  to  express  his  deep  obligation  to  his 
associate  Dr.  Robert  E.  Soule  for  his  cordial  collaboration.  He 
is  also  indebted  to  Dr.  Penn-Gaskell  Skillern,  Jr.,  for  his  most 
valuable  criticisms,  corrections  and  suggestions. 

Fred  H.  Albee. 

40  East  41st  Stkeet, 

New  York  City. 

October,   19L5. 


CONTENTS 

CHAPTER  I 

Page 

The  Fundamextal  Principles  Underlying  the  Use  of  the  Bone 

Graft  in  Surgery 17 

CHAPTER  II 

Author's  Electric  Motor  Operating  Outfit  and  Technique  of 

Usage 52 

CHAPTER  III 

The  Bone  Graft  in  the  Treatment  of  Pott's  Disease  and  Other 

Lesions  of  the  Spine      64 

CHAPTER  IV 

The  Inlay  Bone  Graft  in  the  Operatfv'e  Treatment  of  Fractures  .    149 

CHAPTER  V 

Operative  Methods  for  Remodelling  or  Ankylosing  the  Hip- 
Joint 242 

CHAPTER  VI 

The  Inlay  Bone  Graft  for  Fixation  op  Tuberculous  Knee-Joints; 
Infantile  Paralysis; Osteoarthropathy  (Charcot's  Disease); 
The  Wedge  Graft  for  Habitual  Dislocation  of  the  Patella  .   276 

CHAPTER  VII 

The  Bone  Graft  in  the  Treatment  of  Diseases  and  Deformities 

OF  THE  Foot  and  Leg 308 

CHAPTER  VIII 

Miscellaneous  Surgical  Uses  of  the  Bone  Graft 357 


Index  of  Names 407 

Index 409 


15 


BONE-GRAFT  SURGERY 


CHAPTER  I 


THE  FUNDAMENTAL  PRINCIPLES  UNDERLYING  THE  USE  OF 
THE  BONE  GRAFT  IN  SURGERY 

Cellulai'  life  may  be  quite  independent  of  organic  or  somatic 
life  and,  under  favorable  conditions,  tissue  cells  may  retain 
their  viability  long  after  being  detached  from  the  living  organ- 
ism. ''The  remarkable  viability  of  transplanted  periosteum 
has  been  demonstrated  by  Grohe  and  Morfurgo,  the  former 
showing  that  it  is  capable  of  preservation  for  100  hours  and  yet 
able  to  be  implanted  and  exert  its  osteogenetic  powers.  The 
latter  (Morfurgo)  has  shown  the  periosteum  of  a  corpse  kept  at 
15°  can  produce  new  bone  when  implanted  after  168  hours." 
— Janeway.  The  duration  of  this  cellular  life  depends  largely 
upon  the  means  of  preservation  of  the  detached  parts  or,  in  the 
case  of  organic  death,  the  preservation  of  the  whole  cadaver, 
and  also  upon  the  amount  of  disintegration  from  the  cause  of 
death.  It  is  on  account  of  this  phenomenon  that  detached 
portions  of  living  tissues  can  be  successfully  transplanted  from 
a  corpse  to  a  living  organism.  The  higher  the  specialization 
ol  the  cell  the  less  marked  are  its  resisting  and  proliferating 
powers.  This  is  especially  well  illustrated  in  the  case  of  tissue 
grafts.  The  lower  order  of  tissues,  which  need  less  nutrition, 
continue  to  live  for  days  on  their  own  substance  which  is  con- 
tained in  the  serum  that  permeates  them,  but  the  more  highly 
specialized  ones  are  liable  to  necrosis  in  a  short  time  unless 
nourished  by  a  blood  circulation.  This  viability  varies  with 
the  individual  tissue,  as  the  higher  the  development  of  the  cell 
— such  as  the  ganglion  or  parenchymatous  cells — and  the  richer 
the  tissue  is  in  blood-vessels,  the  less  likely  it  is  to  survive. 
2  17 


18  BONE-GRAFT   SURGERY 

The  most  favorable  tissues  for  grafting  i)urposes  are  the 
simpler  connective  tissues,  such  as  bone,  fat,  fascia,  etc.,  which 
are  endowed  with  the  capacity  of  extracting  nuti'ition  from  the 
soil  into  which  they  are  planted  and  at  the  same  time  are  able 
to  regenerate  so  that  the  portion  of  the  graft  which  disintegrates 
is  replaced.     Muscles  and  nerves  are  most  unfavorable. 

Bone  has  been  successfully  transplanted  since  1809,  when 
]\Ierrem  obtained  successful  healing  of  bone  plates  in  the  skulls 
of  animals  after  trephining.  Subsecjuently,  Walther,  in  apply- 
ing this  technique  to  the  human  subject,  secured  partial  healing 
of  the  graft,  in  spite  of  the  co-incident  suppuration.  In  1858, 
Oilier,  after  extensive  investigations  in  the  use  of  the  bone  graft 
in  both  animals  and  man,  concluded  that  fresh  bony  tissue, 
covered  with  periosteum,  remains  viable.  Autogenous  grafts, 
or  those  derived  from  the  same  individual  into  which  they  are 
engrafted,  are  by  far  the  most  trustworthy.  The  fluids,  al- 
bumins, and  tissues  of  every  individual  vary  in  degree  from  those 
of  every  other,  and  while  this  incompatibility  may  be  slight,  it 
is  sufficient  cause  for  using,  whenever  feasible,  the  individual's 
own  tissue  for  the  repair  of  his  defects. 

With  primary  union  and  in  the  absence  of  infection,  autogen- 
ous bone  grafts,  properly  contacted,  are  always  successful,  and 
even  infection  does  not  necessarily  indicate  failure.  "The 
vegetative  capacity  of  the  bone  cell  is  as  great  as  that  of  the 
epithelial  cell,  and  if  one  grants  not  only  the  viability  of  the 
transplanted  epithelium  but  also  its  power  of  extensive  prolifera- 
tion, then,  judging  by  analogy,  the  bone  cell  ought  to  show,  as  it 
has  bone  in  this  instance,  equal  capabihty  of  living  and  growing 
when  transplanted.  In  proportion  to  the  size  of  the  graft,  the 
smaller  the  graft  the  greater  the  proliferation." — Macewen. 

The  knowledge  of  the  exact  histological  role  which  the  bone 
graft  plays  is,  fortunately,  immaterial  to  its  clinical  usefulness, 
whether  it  serves  as  an  osteoconductive  scaffold  or  as  an  active 
osteogenetic  force.  The  extensive  experiments  and  histological 
studies  of  Oilier,  Macewen,  Frangenheim,  Cotton  and  Loder, 
McWilliams,  Mayer,  Phemister,  and  the  author  (see  Chap.  Ill), 


FUNDAMENTAL    PRINCIPLES  19 

have  proved  the  viabiUty  and  osteogenesis  of  the  grafts  when 
inserted  by  the  proper  technique. 

Cotton  states:  ''Our  specimens  show  a  practically  uniform 
survival  of  the  transplant  when  the  technique  is  adequate. 
The  articular  transplant  of  the  cartilage  usually  shows  no  gross 
change  in  color  or  texture  from  that  of  the  surrounding  undis- 
turbed joint  surface.  The  fragment  very  rapidly  becomes  firmly 
fixed  in  place.  Histological  preparations  obtained  at  varying 
intervals  show  a  series  of  changes  in  the  bony  portions  of  the 
grafts,  the  more  important  of  which  are  constant  and  very  defi- 
nite. The  essential  picture  shown  is  briefly:  (1)  the  early  dis- 
appearance of  the  bone  corpuscles  in  the  transplanted  trabeculse 
and  in  the  trabeculse  of  the  host  bone  for  a  short  distance  from 
the  wound  surface;  (2)  without  any  loss  of  substance  in  (or  any 
marked  foreign  body  reaction  around)  the  bone  from  which  the 
corpuscles  have  disappeared,  this  bone  was  rapidly  and  com- 
pletely covered  by  a  layer  of  new^  endosteal  bone,  which  unites 
with  endosteal  bone  of  the  host;  (3)  the  new  bone  is  laid  down 
by  the  activity  of  end-osteoblasts  in  all  portions  of  the  grafts, 
centre  as  well  as  periphery.  It  has  not  yet  been  proved  that 
some  of  the  end-osteoblasts  which  are  active  in  the  graft  may 
not  have  originated  from  the  endosteum  of  the  host  and  ex- 
tended, or  even  emigrated,  from  it  to  the  graft;  but  no  one,  after 
study  of  our  sections,  can  doubt  that  in  part,  at  least,  these 
osteoblasts  represent  the  actively  proliferating  covering 
membrane  of  the  transplanted  trabeculse;  (4)  practically  no 
changes,  either  of  degeneration  or  proliferation  in  transplanted 
articular  cartilage,  at  least  up  to  4  weeks," 

McWilliams  concludes  in  a  recent  pubUcation:  "Living  bone 
grafts  have  life  inherent  in  themselves,  and  the  theory  that 
contact  with  living  bone  is  necessary  for  subsequent  life  of  the 
graft  must  be  given  up," 

''As  important  as  the  properties  of  the  transplant  are  the 
pualities  of  the  "wound  soil"  which  serves  the  function  of 
supplying  as  quickly  as  possible  nutrition  to  the  graft.  The 
first  step  in  the  establishment  of  the  lymph  flow  and  the  cir- 


20  BONE-GRAFT    SURGERY 

culatioii  is  tlie  early  adhesion  between  wound  edges  and  the  trans- 
plant. The  more  quickly  and  surely  this  takes  place,  the  more 
promptly  is  nourishment  assured.  Should  the  cells  of  the 
wound  he  injured  because  of  antiseptic  applications,  or  should 
they  be  abnormal  because  of  the  presence  of  scars  or  hsemato- 
mata,  or  the  seat  of  previous  disease,  as  tuberculosis,  necessary 
nutrition  will  be  delayed.  Very  important  contributing  factors 
to  failure  are  errors  in  operative  technique,  causing  infection  with 
a  very  slight  transudate,  which  is  instrumental  in  destroying  the 
first  intimate  contact,  thus  preventing  nutrition,  partially  or 
absolutely,  and  predisposing  to  partial  or  total  necrosis  due  to 
suppuration.  By  means  of  strict  asepsis,  this  element  of  failuie 
can  be  eradicated.  Most  important,  however,  is  a  second  factor, 
which  prevents  the  early  intimate  adhesion  of  the  wound  edge, 
namely,  imperfect  hsemostasis.  The  presence  of  the  slightest 
amount  of  blood  is  dangerous,  as  it  interferes  with  the  nutrition. 
That  this  factor  has  been  heretofore  disregarded  is  apparent 
from  the  literature.  It  is  the  general  belief  that  a  smooth,  un- 
infected wound  is  a  sign  of  perfect  technique.  This  is  not  true 
in  connection  with  transplantation.  In  this  instance,  perfect 
technique  is  recognized  by  a  complete  gumming  and  co- 
aptation of  the  wound  edges.  For  this  reason,  every  experi- 
menter in  recording  the  results  of  his  transplantations  should 
convince  himself  that  the  transplant  is  really  grafted  as  it  should 
be,  in  order  that  his  operation  be  perfect." — Lexer. 

Homoplastic  grafts  are  those  which  are  derived  from  another 
individual  of  the  same  species,  and  when  composed  of  the  lower 
order  of  tissues,  such  as  bone  or  fascia,  they  may  be  employed 
successfully,  though  not  with  the  same  certainty  as  autogenous 
grafts;  when  they  consist  of  the  more  highly  specialized  tissues, 
they  result  in  failures.  Homoplastic  grafts  are  often  difficult  to 
obtain,  and  there  always  exists  the  danger  of  transmitting  dis- 
ease from  the  donor  to  the  host,  even  when  the  greatest  care  has 
been  exercised.  Fibrous  encapsulation  occurs  more  frequently 
in  homoplasty  than  in  autoplasty.  This,  as  Lexer  has  pointed 
out,  is  probably  due  to  the  irritation  of  a  foreign  proteid,  which 


FUNDAMENTAL    PRINCIPLES 


21 


varies  most  with  difference  in  race, 
next  with  distant  relatives,  near  rela- 
tives, and  least  with  the  individuals 
of  one  family.  This  variation  pre- 
vents proper  nourishment  of  many 
tissues  and,  as  a  result,  substitution 
in  the  regenerative  process  occurs 
very  slowly  while  degeneration  takes 
place  rapidly. 

Heteroplastic  grafts  are  those 
which  are  obtained  from  an  individ- 
ual of  another  species.  Living  grafts 
from  different  species  may  die  when 
implanted  into  man  or  the  higher 
animals.  The  graft  in  these  cases 
acts  as  a  foreign  body,  and  if  there 
is  even  mild  infection  it  is  liable  to 
ulcerate  out.  In  the  event  of  no  in- 
fection, it  either  becomes  encapsulated 
or  disappears,  and  is  slowly  substituted 
by  the  proliferation  and  migration 
of  the  tissues  in  which  it  is  embedded. 
This  process  may  require  months  in 
the  case  of  the  bone  graft,  and  thus 
it  follows  that  the  graft  may  be  a 
success  clinically,  though  histologic- 
ally it  undergoes  partial  or  even  com-  two^g^rafi^^a^cr^rrionTin! 
plete   absorption,  or,  in  other  words,     '"r''^''^ ,  ^y  the   author  for  a 

_  .  tibial  defect  from   the  removal 

it  acts  as  an  osteoconductive  scaffold,     of  two-thirds  of  its  shaft  for 

sarcoma.  It  was  necessary  to 
amputate  the  leg  just  4  weeks 
after  the  insertion  of  the  grafts,  on  account  of  the  recurrence  of  the  sarcoma,  and  in 
this  short  time  the  grafts  had  become  firmly  united  (at  C)  by  solid  bone,  although 
the  diameters  of  the  grafts  both  above  and  below  the  union  remained  the  same  as 
when  implanted.  These  proliferating  callus  bone  cells  could  have  originated  from  no 
other  source  than  the  two  graft  ends,  thus  proving  conclusively  the  active  osteogenesis 
of  these  free  grafts.  The  efficiency  of  the  bone  graft  could  not  be  better  demon- 
strated than  by  this  specimen.  A,  indicates  where  firm  union  has  occurred  between 
the  upper  graft  and  the  upper  remaining  end  of  the  tibia;  B,  where  the  lower  graft 
has  become  united  to  the  lower  fragment  of  the  tibia;  C,  indicates  firm  bony  union 
between  the  two  graft  ends  which  were  contacted  in  the  centre  of  the  leg  far  away  from 
any  other  possible  source  of  new  bone. 


22 


BONE-GRAFT   SURGERY 


The  principixl  dilliculty  witli  heteroplastic  grafts  is  that 
the  albumins  of  different  individuals  are  not  alike.  Successful 
experiments  are  reported  as  under  way  in  Lexer's  clinic,  with  the 
object  of  changing  the  blood  by  preliminary  treatment.     Kutt- 


FiG.   2. — By  the  kindness  of  Mr.  Robert  Jones.     Tibial  graft  AB,  placed  to  restore 
the  tibia  lost  from  osteomyelitis.     The  graft  has  broken  at  C.      (See  Fig.  -3.) 

ner  has  been  partially  successful  in  grafting  tissue  from  the  ape 
to  man.  The  cellular  mass  necroses,  as  it  may  in  homoplasty. 
Clinical  success  in  the  repair  of  large  denuded  bony  cavities  can 
be  secured  only  by  the  use  of  living  autogenous  bone  covered 
with  periosteum. 


FUNDAMENTAL    PRINCIPLES 


23 


Just  what  happens  to  the  autogenous  bone  graft  from  a  mi- 
croscopical standpoint,  is  still  a  matter  of  discussion.  Whether 
the  boue  graft  lives  as  such,  or  whether  the  cells  wander  into 
it  from  the  bone  with  which  it  is  connected,  is  still  sub  judica. 


A"^ 


Fig.   3.— By  the  kindness  of  Mr.  Robert  Jones.      AB  indicates  firm  union  and  callus 
thrown  out  by  the  graft  fragments. 

In  the  author's  experience  both  with  human  beings  and  with 
animals,  perfect  union  of  the  autogenous  aseptic  bone  graft  with 
the  bone  into  which  it  was  placed  has  been  secured  in  100  per 
cent,  of  cases,  and,  after  all  is  said,  this  is  the  important  consi- 
deration. 


24  BONE-GRAFT    SURGERY 

The  subject  of  the  bone  graft  is  being  widely  (.liscussed,  and 
the  men  who  are  studying  this  problem  may  be  divided  into  two 
schools:  those  who  claim  that  a  certain  portion  of  the  cells  in 
the  graft  live  and  that  the  graft  is  a  distinct  and  separate  osteo- 
genetic  force;  and  those  who  claim  that  the  cells  of  the  graft  do 
not  per  se  have  any  osteogenetic  power  and  that  the  graft  merely 
serves  an  osteocondiicti\'e  purpose.  There  are  at  present,  how- 
ever, very  few  who  continue  to  uphold  the  latter  view,  especially 
since  Earth,  its  originator,  has  been  convinced  that  his  former 
position  was  wrong  and  that  the  cells  of  a  portion  of  an  autog- 
enous periosteum-covered  bone  graft  live  and  play  an  important 
osteogenetic  role  (see  Figs.  1  and  3). 

One  should  not  be  too  dogmatic  concerning  the  exact  role 
that  every  graft  must  play.  Individual  conditions  or  individual 
environment  determine  the  exact  role  of  each  particular  graft. 
There  may  be  a  considerable  blood -clot,  or  tissue  shreds,  which 
interfere  with  the  nourishment  of  the  graft,  preventing  an  imme- 
diate and  perfect  union;  or  there  may  be  a  sHght  or  severe  infec- 
tion, or  other  disturbances  to  deal  with,  and  these  conditions 
determine  the  exact  histology  in  each  individual  case  or,  in  other 
words,  how  many  of  the  graft  cells  have  received  sufficiently 
early  nutrition  and  remain  viable,  and  how  much  of  the  graft 
dies  and  serves  in  an  osteoconductive  role.  It  fortunately  does 
not  matter,  from  a  surgical  standpoint,  what  happens  histo- 
logically, so  far  as  the  exact  role  of  the  graft  is  concerned.  It  is 
known  that  an  autogenous  bone  graft  always  "takes"  and 
becomes  permanent,  if  it  is  put  in  under  aseptic  conditions; 
and,  if  it  has  function  to  perform,  it  stays  there  and  adapts 
itself  in  structure,  size,  contour,  and  in  strength  to  the  new 
environment. 

Boiled  bone  has  been  used  by  Kausch  and  others  for  years 
as  a  substitute  for  the  bone  graft.  From  a  recent  discussion  of 
this  matter,  one  would  gather  that  this  material  had  never  been 
used  before.  Boiled  bone  is  far  inferior  to  an  autogenous  bone 
graft,  and  Kausch,  in  1910,  from  an  extensive  experience  pre- 
pared a  table  illustrating  the  scale  of  value  of  dilTerent  material 


FUNDAMENTAL    PRINCIPLES 


25 


for  bone  substitution  and  made  the  following  statement:  Boiled 
bone  and  bone  from  the  cadaver  are  not  adapted  for  implantation 
in  a  bed  free  from  periosteum,  and  foreign  substances  are  still 
less  suitable  for  this  purpose. 


Fig.  4. — An  antero-posterior  longitudinal  section  of  a  spine  2  years  after  the  tibia 
bone  graft  had  been  implanted  into  its  split  spinous  processes  to  ankylose  the  tuberculous 
infected  vertebrce  present  between  A  and  B. 

The  drawing  was  made  from  an  actual  specimen  and  represents  the  alteration  which 
has  taken  place  in  the  character  of  the  graft  and  its  bed. 

The  area  A  to  5  has  been  so  changed  that  it  presents  the  characteristics  of  a  single 
bone  with  a  distinct  cortex  enclosing  cancellous  bone  structure  throughout  or  in  other 
words  it  has  become  identical  in  its  anatomical  structure  to  the  spinous  processes  to 
which  it  has  become  amalgamated. 

This  is  a  fortunate  characteristic  of  the  bone  graft,  i.e.,  it  adapts  itself  to  its 
environment. 

KAUSCH'S  TABLE   OF  VALUE   OF  DIFFERENT  MATERIALS  FOR  BONE 

TRANSPLANTATION 

1.  Pedunculated  soft  parts  with  periosteum-covered  bone 


flap. 


2.  Free  transplanted  periosteum-covered  autoplastic  bone. 

3.  Free  transplanted  periosteum-covered  homoplastic  bone. 

4.  Fresh  boiled  bone. 

5.  Fresh  preserved  bone. 

6.  Cadaver  or  fetal  bone,  obtained  under  sterile  conditions. 


2G  BONE-GRAFT   SURGERY 

7.  The  same  bono,  boiled. 

8.  Ivory. 

9.  Foreign  bodies,  sucli  as  metal. 

10.  Fresh  animal  bone,  living  or  l)oiled. 

Lexer  states:  ''Boiled  bone,  obtained  fi-oin  a  cadaver,  or 
fresh  bone  which  has  been  sterilized,  acts  as  does  a  foreign  body 
which  slowly  undergoes  substitution;  it  is  rapidly  destroyed  by 
\'igorous  gi'anulations.  Foreign  body  suppuration  with  extru- 
sion of  the  dead  graft,  long  after  primary  union,  occasionally 
occurs." 

Barth  {Verhandlung  der  Deutsch.  Gesell.  fur  Chir.,  xxxviii, 
1909)  makes  this  statement  in  reference  to  boiled  bone  for 
transplantation  purposes:  "Personally,  I  (Barth)  have  had 
nothing  but  failures.  Absorption  follows  in  these  cases,  or  sec- 
ondary suppuration  if  the  patients  are  allowed  to  use  their 
limbs,  and  the  bone  must  be  removed.  I  therefore  believe  that 
it  would  be  going  backward  to  make  use  of  dead  bone  as  a  routine 
measure  in  osteoplastic  work.  Accordingly  it  can  no  longer  be 
doubted  that  in  the  substitution  of  very  large  defects,  only  the 
living  bone  covered  with  periosteum  furnishes  trustworthy 
results." 

Baum  reported  five  cases  of  intramedullary  graft  for  ununited 
fractures.  Four  were  homoplasty  grafts  (taken  from  amputated 
limbs  and  fetal  bones).  The  fifth  graft  was  an  autogenous 
graft  and  was  the  only  one  which  resulted  in  solid  union,  thereby 
proving  the  value  of  live  autogenous  bone  grafts  and  possibly 
the  disadvantage  of  the  intramedullary  technique. 

In  this  connection.  Bier  claims  that  most  bone  regeneration 
comes  from  the  endosteum  and  bone- marrow  and  that  no  re- 
generation occurs  in  a  scraped  (or  reamed-out)  medullary  cavity. 
This  undoubtedly  explains  in  part,  at  least,  failures  from  the 
intramedullary  technique  of  inserting  the  graft  in  ununited 
fractures. 

Implanted  ivory  is  merely  absorbed,  without  any  substitu- 
tion formation  of  new  bone. 


FUNDAMENTAL    PRINCIPLES 


27 


Autogenous  live  bone  is  the  only  material  which  can  be  im- 
planted with  safety  in  a  bed  free  of  perios- 
teum. 

Laewen  made  histological  studies  of  bone 
grafts  which  had  been  transplanted  11 
weeks,  and  by  injecting  the  blood-vessels  of 
the  amputated  arm  found  that  there  had 
been  a  complete  vascularization  of  the 
transplant  which  had  been  obtained  from 
the  tibia  of  the  same  patient.  The  graft 
was  being  gradually  absorbed  and  replaced 
by  new  bone  which  proliferated  from  the  os- 
teogenetic  bone-cells  in  the  periphery  of  the 
Haversian  canals  of  the  graft  itself;  and 
also  the  periosteum  lived  and  was  active  in 
proliferating  new  bone  from  its  deep  osteo- 
genetic  layer.  The  new  bone  always  took 
on  the  contour  of  the  part  which  it  re- 
placed. 

After  extensive  experimental  investiga- 
tions and  a  large  amount  of  human  work, 
the  author  is  convinced  that  the  best  trans- 
plant is  a  live  piece  of  autogenous  bone  in- 

FiG.   5. — A    diagram 

eluding  all  its  elements,  namely,  periosteum,    illustrating  the  method 

,  1       ,  1  used  most  frequently  in 

compact  bone,  endosteum,  and  marrow  grafting  fruit  trees,  it 
substance;  that  the  periosteum  which  is  j:^'^:}:^l^Z 
separated  from  attached  muscles  should  be    three   elements  of    the 

graft   or   scion    (namely, 

-incised  in  numerous  places   to   provoke  a    the  bark,  alburnum  (sap) 

,  i-ij-  11  n  uiJ     and    wood)     are    closely 

greater  stimulation  and  also  a  ireer  blood  coapted  mth  their  cor- 
supply;  it  lets  out  osteogenetic  cells  and  lets  J-P^^f^^^jf  of  "dplnt 
in  nourishment,  that  the  bone  is  best  taken    branch.    This  contact  of 

individual    tissue    layers 

from  the  same  individual  or,  if  this  is  im-    is  most  essential  in  tree 
practicable,  from  another  individual  of  the    ueved  to  be  analogous  to 
nearest  kin,  preferably  a  brother  or  sister;    J;°;^^\  °;:^f°;;g;"  ''"""''^" 
that  the  bone  should  never  be  obtained  from 
an  animal,  because  its  viability  or  replacement  is  uncertain  or, 


// 


28  BONE-GRAFT   SURGERY 

at  best,  delayed,  and  according  to  Axhausen  its  periosteum  does 
\  \  (not  proliferate. 

There  are  certain  fundamental  I'ules  which  should  always  be 
observed  in  the  transplantation  of  all  tissues.  These  rules  must  be 
adhered  to  as  closely  in  the  animal  as  in  the  vegetable  kingdom. 
The  science  of  grafting  in  the  plant  kingdom  is  centuries  old.  The 
most  important  rule  of  the  process  of  grafting  in  the  vegetable 
kingdom  is  the  contacting  of  the  alburnum  of  the  scion  or  graft 


\ 


-> 


Fig.  6.- — -Note  increased  density  of  the  graft  in  (Fif^.  7).     This  rontgenogram  was  taken 
5  weeks  after  the  implantation. 

(which,  in  a  way,  corresponds  to  the  periosteum)  to  the  alburnum 
of  the  stock,  or  the  part  grafted.  (See  Fig.  5.)  The  contacting 
of  the  corresponding  histological  layers  is  not  of  such  paramount 
importance  in  the  grafting  of  bone  as  it  is  in  vegetable  life,  but 
the  importance  of  its  observance  is  unquestionable. 

The  more  closely  these  rules  are  adhered  to,  the  greater  will 
be  the  percentage  of  clinical  successes.  In  the  case  of  the  bone 
transplant,  nature  is  confronted  wdth  the  following  problems: 
(1)  the  rapid  establishment  of  cellular  nutrition  and  blood  supply, 


FUNDAMENTAL    PRINCIPLES  29 

which  is  brought  about  by  the  extension  of  blood-vessels,  and 
by  the  cellular  assimilation  of  the  serum  in  which  the  graft  is 
immersed;  (2)  the  union  of  the  graft  to  the  contacted  bones  or 
fragments  of  bones  by  osteogenesis  on  the  part  of  the  graft  or 
recipient  bone,  or  both;  (3)  through  Wolff's  law,  which  is  the 
adaptation  in  form  and  increased  strength  of  the  graft  to  its 
mechanical  requirements.     If  nature  is  to  succeed  in  accomplish- 


N 


/" 


Fig.  7. — Rontgenogram  of  a  case  of  Pott's  disease  showing  a  tibial  graft  spanning 
three  vertebral  spinous  processes  and  although  this  graft  is  considered  to  be  too  short, 
yet  it  has  held  the  diseased  vertebrte  hyperextended  and  arrested  the  progress  of  the 
disease.  The  principal  interest  of  this  rontgenogram  is  that  it  shows  a  marked  increase 
of  density  of  the  graft  (6  months  after  implantation)  from  functional  stimulation. 
(Wolff's  law.) 

ing  this,  it  is  quite  essential  that  both  the  graft  and  the  recipient 
bone  should  be  favorable  to  cellular  life  and  proliferation. 

The  surgeon  can  do  much  in  aiding  nature  by  strict  asepsis, 
by  minimizing  the  trauma  to  all  the  tissues  involved,  by  avoid- 
ing cellular  death  through  either  bruising  or  comminuting  with 
hand  tools,  or  by  frictional  heat  from  motor-driven  instruments; 
by  the  avoidance  of  traumatism,  thus  guarding  against  necrosis 
of  portions  of  the  graft  and  lessening  the  danger  of  wound  infec- 


30  BONE-GRAFT   SURGERY 

tion;  by  the  proper  protection  and  preservation  of  the  graft  bed 
and  the  graft  itself  from  drying  and  possible  infection;  b}^  so 
arranging  his  skin  incision  that  it  will  not  come  directly  over  a 
superficially  placed  transplant,  as  this  lessens  the  danger  of 
skin  necrosis  and  infection;  by  excising,  if  possible,  extensive 
scars  from  the  field  of  operation,  as  their  poor  blood  supply  is 
likely  to  interfere  with  the  establishment  of  nutrition  to  the 
graft;  by  closely  fitting  and  contacting  bone  surfaces  which 
should,  whenever  possible,  include  the  accurate  coaptation  of 
periosteum  of  graft  to  periosteum  of  recipient  bone,  of  cortex 
to  cortex,  of  endosteum  to  endosteum,  and  of  marrow  to  marrow; 
by  properly  suturing  muscle  origins  and  insertions  to  the  suit- 
able mechanical  locations  on  grafts  which  replace  skeletal  bones 
or  portions  of  them  (this  is  important  if  muscle  control  is  to  be 
reestablished) ;  by  securing  sufficient  hsemostasis  in  the  graft  bed 
by  means  of  repeated  applications  of  hot  saline  solutions,  and 
by  careful  tying  of  blood-vessels.  (A  hsematoma  not  only  favors 
the  development  of  infection,  but  also  interferes  with  the  early 
nutrition  of  the  transplant  by  the  permeating  serum;  a  small 
amount  of  blood-clot,  however,  may  be  desirable);  by  including 
in  the  graft  the  periosteum,  endosteum,  and  marrow,  which  not 
only  contain  active  osteogenetic  elements  but,  on  account  of  their 
loose  structure,  are  more  favorable  than  compact  bone  to  a  rapid 
reestablishment  of  the  blood  supply  with  the  recipient  tissues 
of  the  graft  bed,  from  whence  nourishment  rapidly  reaches  the 
compact  part  of  the  graft  through  the  numerous  blood-vessels 
passing  from  these  enveloping  membranes  into  the  compact 
bone.  In  other  words,  a  bone  graft  consisting  of  all  its  ele- 
ments approaches  more  closely  a  complete  physiological  unit  — 
especially  in  refeience  to  nutritional  distribution — which  is 
obviously  an  advantage. 

Stohr,  in  his  text-book  on  Histology,  states:  ''The  blood- 
vessels of  the  bone,  the  marrow,  and  the  periosteum  are  in  the 
closest  connection  with  one  another  and  also  with  the  surround- 
ing structures.  Small  branches  (not  capillaries)  of  the  numerous 
arteries  and  veins  of  the  periosteum  enter  the  Haversian  and 


PLATE   I 


Fig.  1. — Sixty-four  day  Exp.  No.  153.  One-half  of  the  shaft  .split  longitudinally; 
periosteum  and  endosteuni  on:  «,  Old  dead  cortex;  b,  new  bone  from  periosteum;  c, 
extensive  new  bone  from  endosteuni;  d,  filjrous  intermediary  callus  above;  e,  bony 
union  lower  end.  This  specimen  emphasizes  the  importance  of  the  endosteum  in  the 
production  of  new  Ijone. 


Fig.  2. — Forty-six  day  Exp.  No.  176.  Periosteum  and  endosteum  Ijoth  removed: 
a,  Callus  formed  on  transplant  from  surviving  cells;  b,  dead  cortex;  c,  fibrous  inter- 
mediary calluses.  This  specimen  proves  that  a  cortical  bone  transplant  will  produce 
new  bone  from  its  "  marrow  canals,"  although  all  its  periosteum  and  endosteum  has 
been  removed. 


Fig.  3. — Forty-six  clay  Exp.  161  R.  Showing  rapid  bony  union — a  fracture  through 
a  transplant  with  periosteum  and  endosteum  on:  a,  Bony  periosteal  callus;  b,  bony  en- 
dosteal callus:  c,  bony  intermediary  callus;  d,  cortex  with  colls  dead.  The  rapid  bone 
formation  and  union  in  this  specimen  emphasizes  the  importance  of  coaptating  like  layers 
of  bony  parts,  whether  they  are  fracture  fragments  or  bone-grafts.  There  is  an  important 
correlation  between  these  layers  (viz.,  periosteum,  compact  bone,  endosteum,  and  mar- 
row) in  the  formation  of  bony  callus,  and  a  bone-graft  should  always,  when  possible,  be 
inserted  by  the  inlay  method,  which  brings  all  its  layers  in  coaptation  with  the  corre- 
sponding ones  of  the  host  bone.  According  to  Ely  the  periosteum  furnishes  connective 
tissue  from  which  the  osteoblasts  of  the  marrow  tissue  build  new  bone. 


(D.  B.  Phemister  in  "Surgery,  Gynecology  and  Obstetrics.") 


FUNDAMENTAL    PRINCIPLES  31 

Volkmann's  canals,  which  on  the  inner  surface  of  the  bone  are  in 
communication  with  the  blood-vessels  of  the  marrow.  The  lat- 
ter is  supplied  by  the  nutrient  artery,  which  on  its  way  through 
the  compact  substance  gives  off  branches  to  the  same,  and  in 
the  marrow  breaks  up  into  a  rich  vascular  network." 

The  bone  contact  should  be  of  generous  extent  and  always 
with  healthy  vascular  osteogenetic  bone — the  more  unfavorable 
the  bone,  the  greater  should  be  the  area  of  contact.  Careful 
suturing  as  well  as  accurate  coaptation  should  be  secured  when 
early  use  is  to  be  made  of  the  part,  in  order  to  obtain  the  benefits 
of  functional  irritation.  In  many  instances  where  close  contact 
and  exact  coaptation  cannot  be  secured,  early  bony  union  may 
be  accelerated  by  the  interposition  of  numerous  small  grafts  or 
fragments  of  bone.  In  early  ununited  fractures,  it  is  the  prac- 
tice of  the  author  to  remove  most  of  the  fibrous  union  and  sub- 
stitute for  it  (after  the  inlay  has  been  fixed  in  position)  numerous 
bone  chips  between  the  ends  of  the  fragments.  These  coalesce 
with  each  other  and  also  with  the  graft  and  recipient  fragments. 

The  proper  contact  of  these  bone  elements  can  be  secured 
only  by  the  employment  of  the  author's  inlay  principle  of  pro- 
cedure, which  should  always  be  carried  out  as  carefully  as  cir- 
cumstances permit.  Examples  of  the  various  modifications  of 
this  principle  are  the  inlay  spinal  giaft  for  Pott's  disease,  the 
bone-graft  wedge  for  the  correction  of  deformities,  and  the  inlay 
bone  graft  for  fresh  and  ununited  tractuies.  In  many  of  the 
lattei  type  of  cases,  the  callus  formation  is  so  meagre  that  it  may 
well  be  compared  to  the  cabinet-maker's  glue,  which  will  not 
hold  unless  the  wood  is  exactly  fitted  and  coaptated.  It  will 
not  bridge  space.  The  same  holds  true  in  a  long-existing  un- 
united fracture.  The  surgeon  must  execute  cabinet  bone  work 
in  order  to  approximate  100  per  cent,  of  successful  results,  and 
this  can  be  accomplished  only  by  employing  the  inlay  method 
with  the  author's  bone  mill. 

Bone  grafts  have  been  successfully  applied  by  other  means, 
but  the  following  are  some  of  the  obvious  advantages  of  the 
author's  inlay  method,  besides  the  approximation  of  correspond- 


32  BONE-GRAP^T   SURGERY 

ing  bone  elements  of  "raft  to  recipient  l)one  which  this  procedure 
makes  possible.  In  the  repair  pi-ocess,  especially  in  fractures, 
new  bone  appears  from  both  the  periosteum  and  the  endosteum 
on  both  sides  of  the  cortex,  possibly  more  markedly  on  the  con- 
cave side  of  the  fracture.  The  space  between  an  inlay  bone 
graft  and  its  host  bone  becomes  filled  by  cells  arising  from 
both  the  endosteum  and  the  periosteum.  Cotton  and  Loder 
consider  the  endosteum  as  the  more  important  factor  in  the 
formation  of  bone  about  the  transplant.  In  view  of  these  facts, 
the  inla\  method  of  inserting  a  bone  graft  is  apparent,  in  that  it 
affords  the  coaptation  of  both  these  structures  of  the  graft  to 
the  corresponding  ones  of  the  host  bone. 

The  modifications  of  the  inlay  technique  meet  practically 
all  mechanical  requirements;  it  is  as  applicable  to  fracture  of  the 
small  bones  of  the  forearm  as  of  the  tibia  or  femur;  it  controls 
the  deformity  of  the  foot,  as  well  as  of  spinal  caries;  its  inherent 
mechanics  favor  the  fixation  of  the  graft  as  well  as  the  immobiliza- 
tion of  the  fragments  into  which  it  is  inserted;  its  technique  is 
not  difficult,  because  it  has  to  do  with  plane  surfaces.  The 
inlay  method  allows  the  highest  efficiency  of  Roux's  post-op- 
erative functional  irritation.  To  increase  the  potency  of  this 
factor,  Roux  advises  frictional  dressings  during  the  after  treat- 
ment, which  consist  of  pressing  or  weighting  of  the  bones  and 
stretching  the  tendons. 

That  it  is  not  absolutely  necessary  for  the  success  of  the  graft 
to  be  contacted  with  a  host  bone,  has  been  proved  by  Carter, 
who  states  {Med.  Record,  Feb.  7,  1914):  ''Bone  grafts  either 
covered  by  periosteum  or  bare,  but  accidentally  separated  from 
the  living  periosteum  covered  bone  (host  bone)  appear  to  be 
osteoinductive  and  very  likely  osteogenetic."  He  reports  20 
cases  where  the  bone  graft  was  used  to  elevate  the  bridge  of  the 
nose.  In  many  of  these  cases  the  graft  was  not  contacted  to  the 
bone  of  the  face  but  was  usually  embedded  in  soft  tissue,  never- 
theless the  transplants  are  still  in  place  and  some  are  larger  than 
they  were  when  they  were  implanted  2  or  3  years  before. 

Chiari  has  succeeded  experimentally  in  grafting  portions  of 


FUNDAMENTAL    PRINCIPLES 


33 


bone-marrow  into  the  spleen  of  the  same  animal.  The  grafts 
survived  and  increased  in  size  from  that  of  a  hempseed  at  the 
time  of  transplantation  to  the  size  of  a  pea  5  months  later.  His- 
tological examinations  of  the  grafts  in  the  spleen  showed  that 


Fig.  8. — This  is  a  rontgenograni  of  a  case  of  loss  of  the  lower  one-third  of  the  tibia 
one  year  before  from  osteomyelitis.  The  remaining  periosteum  attempted  to  reform 
the  shaft  and  a  small  interrupted  thread  of  bone  can  be  seen.  It,  however,  either 
became  broken  in  two  places  or  a  complete  bridge  of  bone  was  never  produced;  there- 
fore, the  influence  of  WolfT's  law  did  not  operate  to  stimulate  bone  proliferation  for  the 
tibia  at  A,  as  it  would  have  if  there  had  not  been  a  solution  of  continuity.  The  potency 
of  this  same  Wolff's  law,  however,  could  not  be  better  demonstrated  than  it  is  in  this 
same  rontgenogram,  as  shown  by  the  enormous  hypertrophj^  of  the  fibula,  which  has 
become  the  size  and  strength  of  a  normal  tibia.  This  is  a  physiological  property  of 
bone,  and  shows  itself  as  strikingly  in  bone  grafts  under  functional  stress  as  it  does  in 
complete  skeletal  bones.  Therefore,  as  stated  elsewhere,  at  the  same  time  the  graft 
is  proliferating,  in  order  to  be  of  sufficient  strength  for  its  new  environment,  the  tibia 
from  which  it  was  removed  proliferates  under  the  stimulus  of  function  until  it  has 
returned  to  its  normal  strength  and  size. 

the  growth  was  actually  due  to  an  increase  in  bulk  of  the  specific 
bone-marrow  tissue. 

A  thorough  understanding  of  the  modus  operandi  and  theory 
of  Wolff's  law  is  imperative.  The  influence  of  this  law  upon 
the  success  of  bone-grafting  procedures  of  all  kinds  cannot  be 


34 


BONE-GRAFT   SURGERY 


too  strongly  eiiipluisizcd.  It  not  only  influences  the  graft  to 
proliferate  and  strengthen  to  an  almost  unlimited  degree,  if 
the  new  mechanical  cinironmont  of  the  gnii't  re(iuires  it,   but 


-2-* 


Fig.  9. — AntLiiur  iJO.-tLiior  and  lateral  rontgenograms  of  a  tibia  from  which  a  graft 
had  been  removed  for  Pott's  disease  12  weeks  before.  AB  indicates  location  from 
which  graft  was  removed.  The  cavity  has  filled  in  and  under  influence  of  Wolff's  law 
the  tibia  has  become  nearly  if  not  as  strong  as  it  was  before  the  graft  was  removed. 

the  action  of  this  law  also  causes  the  bone  from  w^hich  the  graft 
was  removed  to  be  restored  to  its  original  strength.  (See  Fig  9.) 
This  same  influence  also  causes  internal  reconstruction  of  not 


FUNDAMENTAL    PRINCIPLES  35 

only  the  trabeculse,  as  the  mechanical  forces  demand,  but 
also  of  the  general  histological  character  of  the  bone,  i.e., 
cortical  bone  ultimately  becomes  spongy  bone  if  implanted 
in  or  contacted  with  bone  of  that  character,  and  vice  versa. 
(See  Fig.  4.) 

A  brief  statement  of  Wolff's  law  is  as  follows:  ''Every 
change  in  the  form  and  position  of  the  bones  or  of  their  function 
is  followed  by  certain  definite  changes  in  their  internal  archi- 
tecture, and  by  equally  definite  secondary  alterations  of  their 
external  conformation,  in  accordance  with  mechanical  laws." 

The  question  as  to  what  factors  control  the  growth  and 
development  of  a  transplanted  bone,  or  fragment  of  bone,  and 
cause  it  to  take,  later  on,  the  size  and  shape  of  the  bone  which 
it  replaces,  is  a  most  interesting  one.  It  is  undoubtedly  inti- 
mately connected  with  the  corresponding  problem  of  the  factors 
concerned  in  the  development  of  normal  bones.  Museum 
specimens  and  Nichols'  cases  (reported  in  Jour.  A.  M.  A.,  Feb. 
3,  1914)  demonstrate  that  when  a  new  bone  casing  or  involucrum 
is  thrown  out  around  the  necrotic  shaft  of  a  long  bone,  it  is 
thicker  opposite  the  middle  of  the  shaft  than  at  the  ends. 

The  physiological  repair  of  fractures  badly  reduced,  with  a 
wide  separation  of  fragments,  and  the  restoration  of  the  original 
contour  of  the  shaft  of  that  bone  from  the  two  over-lapping 
broken  ends,  demonstrates  clearly  w^hat  can  be  done  by  diaphy- 
seal osteoblasts,  apart  from  the  aid  of  the  epiphyseal  cartilage, 
in  not  only  restoring  the  external  contour  but  also  the  medullary 
canal  of  the  original  bone.  The  osteoblasts  will  not  only  restore 
the  outlines  of  a  fractured  fibula  or  form  a  new  fibula  shaft  but, 
as  has  been  demonstrated  by  Huntington,  Stone,  Bond,  and 
others,  they  will  transform  a  transplanted  fibula  into  a  new 
tibia.  Skiagrams  show  that  not  only  does  bone  deposit  on  the 
outside  of  the  shaft,  but  the  medullary  canal  is  enlarged  and  the 
fibula  thus  approximates  the  structure,  size  and  contour  of  the 
normal  tibia.  Bond  believes  that:  "This  must  be  the  outcome 
of  original  hereditary  capacity  on  the  part  of  the  osteoblast  con- 
cerned, as  w^ell  as  the  result  of  new  pressures  and  strains  ex- 


•M\  BONE-GRAFT   SURGERY 

])('i-i(MU'(Ml  hy  tlu'sc  hone-cells  dui-iiiu;  llicii'  ^I'owtli  uiidei- altered 
condition^.  This  imist  mean  that,  althoiig-h  ii  eonsiderable 
amount  of  yoiinti;  hony  mateiial  may  have  been  supplied  by 
osteoblasts  from  the  shaft  and  ends  of  the  fibula — when  used 
to  rei)la('e  the  tibia  —vet  the  real  task  of  modelling  the  new  bone 
thus  thrown  out  and  of  dejiositing  it  in  the  right  situations  must 
fall  upon  the  osteoblasts  of  tibial  ancestry,  upon  bone-cells  which 
are  thi-own  out  by  the  tibial  extremities  after  these  have  been 
rejoined  by  the  interposition  of  a  new  shaft." 

The  way  in  which  osteoblasts  derived  from  separate  bones 
may  woi-k  in  coordination  to  build  up  bony  trabecuUe  in  situa- 
tions of  stress  is  well  illustrated  in  Fig.  212,  showing  excision  of  a 
knee,  with  ankylosis  of  the  femur  and  tibia  at  a  right  angle  to 
each  other.  Under  the  mechanical  disadvantage  of  the  two 
longest  bones  in  the  body  being  united  into  one  at  a  right  angle, 
the  bony  trabeculse  have  arranged  themselves  to  carry  the  weight 
of  the  body  and  this  result  has  been  arrived  at  by  osteoblasts  of 
femoral  and  tibial  origin,  each  having  taken  part  in  the  forma- 
tion of  the  new  bone.  ''The  key-note  of  all  bone  development 
seems  to  l^e  a  co(")rdinated  arrangement  of  bone-cells  in  lateral 
and  end-on  relations  to  each  other  under  the  stimulus  of  pressure 
and  strain  within  certain  limits  of  innate  capacity." — (Bond.) 

This,  in  brief,  is  Wolff's  law,  which  always  requires  a  bony 
connecting  medium  if  its  influence  is  to  be  potent.  In  the  same 
way,  a  shaft  seems  to  be  essential  to  the  proper  growth  of  all 
epiphyses — all  of  which  is  in  confirmation  of  Murphy's  state- 
ment that  "the  amount  of  growth  in  a  bone  depends  on  the  need 
for  it."  The  bone-cell  colony  has  its  investing  and  limiting 
membrane,  the  periosteum,  just  as  the  liver  has  its  capsule  and, 
as  Macewen  has  shown,  this  periosteum  or  bone-capsule  serves 
to  keep  the  bone-cells  within  circumscribed  limits  and  prevents 
them  from  invading  neighboring  tissue.  The  fact  that  the 
transplanted  fibula  shaft  develops  into  a  bone  of  the  size  and 
shape  of  the  tibia,  shows  that  the  failure  to  do  so  in  some  cases 
is  not  due  primarily  to  the  fact  that  the  transplanted  bone  is 
naturally  a  smaller  bone,  but  to  the  fact  that  it  is  not  median- 


FUNDAMENTAL    PRINCIPLES  37 

ically  sufficiently  taken  over  or  that  its  growth  is  not  sufficiently 
stimulated  by  osteoblasts  of  tibial  origin. 

Bond  has  suggested  the  following  theory:  ''It  may  not  be 
entirety  useless  to  regard  for  the  moment  an  individual  bone  as 
an  organ,  to  think  of  it  as  a  mass  of  bone  cells  of  definite  ancestry 
whose  activities  are  exercised  in  becoming  adapted  to  a  physical 
environment  of  definite  stress  and  strain."  If  this  supposition 
be  true,  the  selection  of  the  bone  from  which  the  graft  is  to  be 
used  becomes  of  the  greatest  importance,  as  the  degree  of  possi- 
ble cellular  proliferation  of  grafts  or  fragments  of  bone  would  be 
determined  by  the  size  and  strength  of  the  bone  from  which 
they  were  removed.  This  would  argue  in  favor  of  obtaining 
grafts  from  a  large  and  active  bone,  such  as  the  tibia,  when  they 
are  to  be  placed  in  an  environment  where  it  is  necessary  for 
them  actively  to  proliferate  and  withstand  a  large  amount  of 
functional  stress.  Under  this  supposition,  a  graft  obtained  from 
a  rib  would  not  have  the  mechanical  possibilities  of  a  tibial 
graft,  but  would  be  suitable  for  the  correction  of  facial  bony 
defects,  as  was  so  well  demonstrated  by  Carter,  or  for  any  pur- 
pose where  excessive  mechanical  stress  is  not  required. 

The  external  shape  of  the  bone  is  the  result  of  functional 
adaptation.  The  bone  is  strengthened  and  thickened  at  those 
points  where  most  stress  and  pressure  come  upon  it,  and  is 
weakened  at  the  opposite  points.  Such  transformations  have 
the  object  of  enabling  the  bones  or  grafts  in  their  altered  posi- 
tions and  relationships  to  meet  the  new  and  abnormally  directed 
stress  upon  them. 

A  good  illustration  of  the  influence  of  Wolff's  law  is  where  a 
portion  of  the  tibia  has  been  destroyed  by  osteomyelitis  and  re- 
moved. Without  the  support  of  the  tibia,  the  use  of  the  leg 
causes  an  abnormal  amount  of  stress  from  both  weight-bearing 
and  muscular  pull  to  be  borne  by  the  fibula,  which  hypertrophies 
up  to  a  strength  commensurate  with  this  added  strain.  (See  Fig. 
8.)  The  same  thing  happens  to  a  graft  which  is  not  of  sufficient 
diameter  to  withstand  the  stress  that  comes  upon  it — it  prolifer- 
ates to  an  adequate  size.     Again,  the  tibia  or  bone  from  which  the 


38  BONE-GRAFT   SUKGERY 

graft  has  been  removed  proliferates  until  it  becomes  of  the  same 
size  and  strength  that  it  was  before  the  graft  was  removed;  and 
this  occurs  in  about  two  to  four  months,  if  the  skiagrams  can  be 
trusted.  Thus  it  is  seen  that  Wolff's  law  has  to  do  with  function 
and  is  operable  in  fragments  of  bone  as  well  as  complete  skeletal 
bones,  and  that  it  has  an  important  bearing  upon  the  plan  of 
treatment  and  the  progress  of  convalescence  in  a  very  large  por- 
tion of  bone  and  joint  work. 

Local  or  general  hypertrophy  of  a  bone  may  occur.  Local 
hypertrophy  may  occur  in  consequence  of  increased  strain  upon 
certain  parts  of  a  graft,  either  directly  or  through  the  muscle 
pull.  Schulze-Berge  {Central  fiir  Chir.,  No.  48,  1913,  p.  1854) 
reports  the  removal  of  the  knee  joint,  including  8  cm.  of  head  of 
tibia,  for  spindle-cell  sarcoma,  and  the  substitution  of  a  segment 
of  the  fibula  from  the  opposite  leg.  Radiographs  taken  1  year 
later  showed  that  the  transplant  had  attained  the  strength  and 
size  of  the  diaphysis  of  the  tibia. 

The  recognition  and  full  appreciation  of  these  important  con- 
clusions of  Wolff  constitute  the  foundation  of  the  treatment  of 
deformities  and  the  application  of  grafts  of  all  kinds.  It  is 
obvious  that  it  is  always  advisable  to  allow  the  graft  to  function- 
ate as  early  as  possible  by  bearing  mechanical  stress  within  the 
limits  of  safety.  This  is  highly  favorable  to  osteogenesis,  estab- 
lishment of  blood  supply,  and  bony  union.  This  functionating 
period  should  be  preceded  by  the  most  efficient  fixation  of  the 
parts  grafted  for  an  interval  of  not  less  than  8  weeks. 

THE  ROLE   OF  THE  PERIOSTEUM 

It  is  largely  a  question  of  the  definition  of  what  the  peri- 
osteum is  and  what  it  includes  as  to  whether  it  is  to  be  considered 
actively  osteogenetic  or  not.  If  by  chance  the  cleavage  is  deep, 
as  when  the  periosteum  is  removed  with  a  sharp  elevator  and 
the  underljdng  cortical  bone  scraped,  the  periosteum  is  sure  to 
be  actively  osteogenetic,  and  it  is  only  by  this  technique  that 
the  whole  anatomical  or  histological  periosteum  is  secured.     On 


FUNDAMENTAL    PRINCIPLES  39 

the  other  hand,  if  the  normal  periosteum  is  stripped  off  or  re- 
moved with  a  blunt  instrument,  the  cleavage  is  not  likely  to  be 
deep  enough  to  include  the  osteogenetic  layer  of  cells  on  the 
periphery  of  the  compact  bone.  In  that  instance  the  periosteum 
constitutes  a  connective-tissue  limiting  membrane  (Macewen) 
only  and  slight  or  no  osteogenesis  occurs. 

Every  graft  should  have  as  large  a  covering  of  periosteum  as 
possible,  because  it  not  only  favors  the  establishment  of  blood 
supply  to  the  graft  but  is  also  an  important  factor  in  influencing 
the  permanency  of  the  graft,  as  was  so  well  demonstrated  by 
McWihiams. 

In  the  study  of  bone  injuries  and  bone  growth,  the  three 
burning  questions  of  the  origin  of  bone  callus,  the  role  of  the 
periosteum  and  of  the  bone  graft  have  largely  dominated  the 
recent  literature. 

In  1692,  Havers,  whose  name  has  been  perpetuated  by  asso- 
ciation with  the  vascular  canals  of  the  bone,  described  the  peri- 
osteum as  a  simple  connective-tissue  "limiting  and  vascularizing 
membrane,"  but  his  work  was  based,  apart  from  mere  specula- 
tion, upon  purely  anatomical  data. 

Antoine  de  Heyde,  in  1684,  published  the  first  experimental 
observations  upon  the  repair  of  fractures,  based  upon  work  on 
frogs,  and  came  to  the  conclusion  that  callus  was  formed  by 
calcification  of  the  blood  which  had  extravasated  around  the 
broken  ends. 

Duhamel  (1739  to  1743)  brought  forth  the  first  systematic 
work  on  this  subject  and  was  the  originator  of  the  generally  ac- 
cepted modern  theory  of  the  reparative  role  of  the  periosteum. 
It  was  his  belief  that  the  periosteum  proliferated  and  became 
thickened  about  a  fracture  and  formed  the  callus  by  throwing 
out  the  new  tissue.  He  was  also  the  first  to  define  and  use  the 
term  ''cambium  layer"  of  the  periosteum  which,  since  the  writ- 
ings of  Macewen,  has  become  recognized  as  the  all-important 
bone-governing  element  of  that  membrane. 

Over  100  years  later,  after  the  less  important  investigations 
of  Troja  and  others,  appeared  the  great  and  important  work  of 


40  BONE-GRAFT   SURGERY 

Oilier  (1858  to  18G7),  which  has  stood  the  test  of  time  and 
remains  to-day  the  principal  foundation  of  all  our  exact  knowl- 
edge of  l)()n(^  growth,  although  for  a  time  it  was  thought  that 
Barth  and  others  had  definitely  refuted  Ollier's  views.  These 
very  men,  however,  have  largely  come  back  to  Ollier's  position. 
His  work  was  so  thorough  and  careful  that  his  conclusions  have 
attained  an  almost  unassailable  position.  He  proved  the  re- 
generation of  ])one  from  periosteum  in  every  possible  way,  and 
ever  since  his  day  the  periosteum  has  been  regarded  as  the  most 
important  vital  tissue  of  the  bone.  Nearly  50  years  have  elapsed 
since  Ollier's  treatise,  and  during  this  period  practically  the  whole 
of  modern  surgery  has  arisen.  Very  many  w^orks  have  been 
written,  dealing  with  fractures  experimentally  produced,  but 
these  have  chiefly  concerned  themselves  w^ith  the  structure  and 
origin  of  callus.  More  recently,  the  practical  question  of  filling 
bone  defects  by  grafts  of  dead  or  living  bone  obtained  from  vari- 
ous sources  has  absorbed  the  attention  of  workers  who  have 
sought  to  examine  experimentally  this  method  of  bone  recon- 
struction (Groves).  Most  important  contributions  on  the 
subject  have  been  made  by  Axhausen  (1898),  who  showed  that 
certain  portions  of  transplanted  living  bone  retain  their  viability 
and  act  as  the  centres  of  new  bone  proliferation.  Groves  states 
that:  ''Every  practical  worker  on  the  subject  has,  moreover, 
endorsed  the  opinion  that  a  living  bone  of  the  same  species  gives 
much  quicker,  stronger,  and  more  certain  results  than  dead  bone 
or  than  that  taken  from  another  species." 

Living  bone  is  the  chief  source  and  origin  of  callus,  which 
grows  mainly  from  its  outer  or  periosteal  surface  and  to  a  less 
extent  from  its  deep  or  medullary  surface  and  its  cut  or  broken 
ends. 

Oilier,  in  1858,  described  his  technique  for  subperiosteal  re- 
section, but,  so  far  as  I  am  aware,  he  did  not  emphasize  the  im- 
portance of  vigorous  scraping  with  a  sharp  instrument  in  order 
to  separate  with  the  periosteum  the  embryonic  layer  of  active 
bsteogenetic  cells  which  is  situated  on  the  periphery  of  the  com- 
pact bone,  although  it  is  evident  from  the  description  of  his  work 


FUNDAMENTAL    PRINCIPLES  41 

that  he  frequently  practised  this  technique.  It  seems  certain 
that  osteogenesis  on  the  part  of  the  healthy  periosteum  removed 
from  a  healthy  bone  is  largely  dependent  on  the  presence  of  these 
active  embryonic  cells  from  the  outer  surface  of  the  cortical  bone. 
Therefore,  the  wisdom  of  the  use  of  the  sharp  periosteum  eleva- 
tor in  bone  resection  is  apparent  if  a  regeneration  of  bone  from 
the  periosteum  is  desired. 

This  statement,  however,  refers  to  normal  periosteum  re- 
moved from  an  uninfected  bone.     Infection  of  a  bone,  especially 
of  the  marrow  cavity  in  osteomyelitis,   causes  an  immediate 
migration  of  osteogenetic  cells  from  the  Haversian  canals  of  the 
underlying  bone  into  the  loose  areolar  tissues  of  the  periosteum. 
The  meshes  of  this  layer  become  filled  with  osteoblasts,  from 
which  layers  of  bone  later  form.     If  the  pyogenic  infection  be 
progressive,  the  diaphysis  may  be  involved  and  die;  but  the 
osteoblasts  in  the  periosteum,  which  have  escaped  before  the 
necrosis  occurred,  avoid  destruction.     Occasionally  the  whole 
shaft  necroses  without  a  reproduction  of  bone  from  the  periosteum. 
This  arises  from  one  of  at  least  two  causes.     The  first  occurs 
when  the  pyogenic  in^'asion  is  more  virulent,  rapid,  and  exten- 
sive, causing  blockage  of  the  vessels  not  only  of  the  medulla  but 
also   of  the  shaft,   producing  necrosis  without  a  preliminary 
period    of   hypersemia   and    consequently   before   regenerative 
changes  have  had  time  to  occur  in  the  shaft.     The  second, 
where  the  main  nutrient  vessels  of  the  shaft  at  a  very  early  stage 
become  thrombosed  by  pyogenic  invasion,  the  blood  supply  of 
a  large  portion  of  bone  is  cut  off,  and  necrosis  occurs  before  pro- 
liferation within  the  bone  can  take  place.     In  some  of  these 
cases,  the  periosteum  participates  in  the  destructive  process,  but 
it  does  not  do  so  in  all.     Owing  to  its  separate  blood  supply,  it 
is  possible  for  the  periosteum  to  live,  and  it  sometimes  does  so 
apart  from  the  bone.     In  such  a  case,  however,  there  is  no  regen- 
eration of  osseous  tissue,  there  having  been  no  osteoblasts  re- 
generated from  the  bone  and  thrown  from  the  shaft  into  the 
subperiosteal  areolar  tissue  before  necrosis  set  in.     It  is  in  these 
cases  in  which  an  involucrum  fails  to  regenerate  that  the  bone 


42 


BONE-GRAFT    SURGERY 


Fig.  10. — The  author  is  endebted  to  Dr.  Ellis  W.  Jones  of  Los  Angeles,  Cal.,  for  the 
privilege  of  reporting  this  case,  which  was  an  absence  of  one-half  the  tibia  from  an  old 
osteomyelitis.  A  graft  from  the  other  tibia  was  inserted  by  the  author's  inlay  method. 
The  wound  became  septic  (staphylococcus  aureus)  and  the  whole  graft  was  laid  bare; 
nevertheless  the  graft  lived,  and  the  result  was  excellent.      (See  Fig.  12.) 


FUNDAMENTAL    PRINCIPLES 


43 


Fig.   IL— By  the  kindness  of  Dr.  E.  W.  Jones,  Los  Angeles,  Cal.     Same  case  as 

(Fig.  10)  1  month  later.  .  .        c  ti,    k   r,a 

This  case  Ulustrates  splendidly  the  inherent  bacteria-resisting  properties  ol  the  bone 

graft  when  properly  inserted. 


44 


BONE-GRAFT   SURGERY 


Fig.  12. — (Same  case  as  Figs. 
10  and  11.)  A  rontgenogram 
taken  about  3  months  later,  after 
the  wound  had  entirely  healed, 
showing  the  increase  in  size  of 
the  graft  and  its  firm  union  to 
the  tibial  fragments,  indicated  by 
the  arrows.  Also  the  develop- 
ment of  a  medullary  canal. 


gi-aft  is  of  the  greatest  service.  In 
fact,  it  is  in  many  cases  the  only 
possible  means  of  avoiding  an  ampu- 
tation. (For  technique,  see  Chapter 
on  Miscellaneous  Uses  of  the  Bone 
Graft.) 

Davis  and  Hunnicutt,  in  Bulletin 
of  Johns  Hopkins  Hospital,  record 
the  following  findings:  Free  perios- 
teal transplants  did  not  produce 
hone  in  a  large  majority  of  experi- 
ments, even  though  osteoblasts  were 
adherent  to  the  transplants.  Pedun- 
culated flaps  of  periosteum  did  not 
l)roduce  bone.  Free  and  peduncu- 
lated periosteal  flaps  with  bone  shav- 
ings attached  produced  bone  in  each 
experiment.  Autogenous  bone,  both 
with  and  without  periosteum,  lived 
and  was  successfully  transplanted  to 
fill  defects  in  bone. 

Although  not  advisable,  many 
liberties  can  be  taken  with  the  bone 
graft  without  interfering  with  its 
success.  It  has  certain  bacteria-re- 
sisting properties. 

The  author's  experimental  grafts 
were  kept  in  normal  salt  solution  for 
varying  periods  up  to  1  week,  with 
successful  results  following  their  im- 
plantation. In  other  cases,  sepsis 
occurred  immediately  after  insertion 
of  the  graft  (experimental) ;  never- 
theless parts  of  the  graft  became 
united  to  recipient  bone,  while  the 
rest  of  the  implant  sequestrated. 


FUNDAMENTAL    PRINCIPLES  45 

Human  autogenous  grafts  have  been  repeatedly  so  placed 
that,  at  their  middle  portion,  they  extend  through  tubercular 
foci,  and  in  no  instance  has  primary  union  or  taking  care  of  the 
graft  failed.  Likewise,  grafts  have  been  so  placed  as  to  span 
attenuated  pyogenic  infected  areas,  and  here  the  grafts  have 
been  equally  successful. 

.  To  substantiate  the  author's  previous  statement,  based 
upon  animal  experimentation  and  many  similar  surgical  experi- 
ences, that  many  liberties  may  be  taken  with  the  bone  graft 
without  interfering  with  its  success"  (Albee:  Experimental 
Stud}^  of  the  Bone  Growth  and  the  Spinal  Bone  Transplant, 
Jour.  A.  M.  A.,  April  5,  1914),  Galloway  {Western  Cariada  Med. 
Jour.,  April,  1914)  cites  the  following  personal  experiences: 
''I  have  operated  on  four  patients  (bone  graft  for  Pott's  disease) 
in  whom  a  discharging  lumbar  sinus  was  present.  Of  course, 
extra  precautions  were  taken,  the  mouths  of  the  sinuses  and  the 
surrounding  skin  being  thoroughly  disinfected  with  iodine  and 
then  sealed  with  collodion  on  the  day  preceding  the  operation 
and  before  the  regular  pre-operative  disinfection  of  the  patient's 
skin  was  commenced.  In  all  four  cases  primary  healing  took 
place. 

''In  several  instances  where  there  was  a  prominent  kyphosis, 
small  pressure  sores  occurred,  causing  exposure  of  the  edge  of 
the  graft,  but  in  only  two  or  three  of  these  did  any  sequestra- 
tion occur,  and  in  these  not  enough  to  interfere  with  the  success 
of  the   operation. 

''In  one  patient,  pseudo-arthrosis  of  the  tibia,  I  (Galloway) 
put  in  one  graft  which  greatly  improved  the  condition  of  the 
limb  and  became  firmly  healed  in.  The  tibia  could  still  be 
easily  bent,  however,  and  a  second  operation  was  attempted. 
The  first  graft  was  firmly  united  throughout  and  was  firm,  but 
the  recipient  bone,  which  was  noted  to  be  very  soft  at  the  time 
of  the  first  operation,  had  not  improved,  but  was  almost  like 
dense  fibrous  tissue.  A  second  graft  was  then  cut.  In  shaping 
it  after  removal,  it  unfortunately  slipped  out  of  my  hands  and 
fell  upon  the  floor.     It  was  immediately  picked  up,  washed  in 


40  boni-:-(;h.\i"1'  sruGEiiY 

wtitory  solution  ol'  liyilrar^.  biniodide,  1  in  1,00U,  followed  by 
rinsiii<;  with  iioiiiial  snline  solution,  and  was  placed  in  position. 
Mild  sui)|)ur:it ion  loljowcd  but  li('alin<2;  finally  occurred.  Un- 
fortunately, however,  the  recipienl  bone  remained  fibrous  and 
the  limb  faih^l  to  become  firm,  and  T  was  finally  forced  to 
amputate." 

Tiie  author  has  found  that  exjx'i'iniental  grafts  taken  from 
long  bones,  such  as  the  tilna  or  ulna,  showed  evidence  of  greater 
osteogenesis  than  those  taken  from  vertebral  spinous  processes. 
Bone  from  which  the  periosteum  had  been  removed  proved  as 
satisfactory  as  bone  grafts  on  which  the  periosteum  had  not 
been  removed. 

It  is  deemed  advisable,  as  stated  elsewhere,  to  always  include 
the  periosteum  and  marrow  substance,  when  possible,  on  the 
graft. 

The  bone  graft  acts  always  as  a  stimulus  to  osteogenesis  to 
the  bone  into  which  it  is  engrafted  or  to  which  it  is  contacted. 
This  is  a  constant  and  important  factor,  and  may  be  depended 
upon  toward  securing  results.  If  the  graft  is  placed  in  a  loca- 
tion where  there  is  no  mechanical  function  for  it  to  perform  its 
cells  retain  their  vitality,  but  nearly  always  there  will  be  few  or 
no  proliferative  changes  in  the  transplant.  On  the  other  hand, 
if  it  is  transplanted  into  a  defect  where  there  is  a  demand  for  it 
to  perform  a  mechanical  function,  proliferative  changes  are 
usually  marked,  and  it  rapidly  becomes  united  and  similar  in 
structure  to  the  part  into  which  it  is  grafted.  This  is  the  law  of 
functional  irritation  as  laid  dow^n  by  Roux.  The  more  perfect 
the  technique  of  transplantation,  the  greater  will  be  the  effect  of 
this  law  of  irritation. 

The  bone  graft,  when  well  contacted,  becomes  immediately 
adherent  to  the  recipient  bone  by  newly  formed  tissue,  which 
changes  to  solid  bone  within  4  weeks.  In  the  author's  opinion, 
this,  together  with  the  graft's  bacteria-resisting  property,  strongly 
favors,  when  feasible,  the  employment  of  the  bone  graft  in 
place  of  any  metal  internal  splints,  especially  when  it  is  appreci- 
ated that  metal  has  an  effect  opposite  to  that  of  a  graft  in  that  it 


FUNDAMENTAL    PRINCIPLES  47 

inhibits  callus  formation,  produces  bone  absorption,  and  favors 
infection. 

The  dowel,  the  inlay,  and  the  wedge  bone  graft  fulfil  all 
mechanical  requirements  and  afford  a  means  of  re]3airing  and 
remodelling  the  skeleton  which  the  surgeon  has  not  hitherto 
possessed. 

PRESERVATION  OF  THE  BONE  GRAFT 

Various  methods  have  been  suggested  for  the  preservation 
of  bone-graft  material,  but  in  the  experience  of  the  author  the 
following  have  proved  most  convenient  and  reliable. 

The  temporary  immersion  in  normal  salt  solution  is  most 
satisfactory,  and  even  this  is  usually  not  necessary,  since,  when 
possible,  the  graft  bed  should  always  be  prepared  prior  to  the 
removal  of  the  graft,  and  the  graft  is  immediately  implanted  in 
the  prepared  bed.  This  sequence  of  the  operation  is  important, 
because  (1)  it  assures  an  interval  of  time  for  the  more  perfect 
hsemostasis  in  the  graft  bed;  (2)  it  enables  the  surgeon  by  means 
of  calipers,  bone  wax  model  and  flexible  sterile  pattern  rod  or 
flexible  probe  to  obtain  the  exact  size  and  contour  of  the  graft  re- 
quired, thus  avoiding  unnecessary  traumatization  from  holding 
forceps  in  reshaping  a  graft  after  its  removal.  Even  in  grafts 
where  drill  holes  are  necessary,  it  is  far  preferable  to  drOl  the 
graft  before  loosening  it  from  the  bone  from  which  it  is  obtained. 
A  graft  should  always  be  used  as  soon  after  its  removal  as  possi- 
ble, but  if  it  is  necessary  for  any  amount  of  time  to  elapse  before 
it  can  be  used,  normal  saline  is  not  satisfactory  as  a  preserving 
medium  because  of  its  evaporation  and  the  consequent  toxic 
effect.  In  the  experiments  of  the  author,  sterile  vasehne  has 
proved  a  most  satisfactory  medium  in  which  to  keep  the  graft. 
It  is  not  only  perfectly  non-toxic,  but  it  is  an  efficient  preventive 
of  drying.  The  graft  should  either  be  mimersed  in  a  jar  of  vase- 
line or  wrapped  in  gauze  smeared  with  the  same  and  placed  in 
cold  storage  at  a  temperature  of  4°  to  5°  C.  Freezing  is  not 
desirable,  as  the  resultant  contraction  and  expansion  damage 
the  cellular  content  of  the  graft.     Human  grafts  removed  from 


4S  BONE-GRAFT    SURGP^IIY 

(li(>  liNiiiti  as  well  us  lioin  a  cadaver  lia\'e  l)ecii  successfuU}'  kept 
by  the  author  for  48  hours  on  different  occasions.  Emphasis 
sliould  a^aiii.  liowevei-,  l)e  laid  ujion  the  importance  of  using  au- 
togenous l)one  grafts  whenever  possible,  as  they  are  the  most 
reHai)lo;  and  as  they  are  always  used  immediately,  no  preserving 
medium  is  n(^cessary. 

The  surgical  status  of  the  value  of  the  bone  graft  has  now 
become  so  thoroughly  established  that  the  surgeon  should  be 
ready  and  equii)pc(l  to  make  the  best  use  of  it  in  every  indi- 
vidual case  requiring  osteoplasty.  An  unabridged  enumeration 
of  the  indications  for  the  employment  of  the  bone  graft  would 
be  most  difficult,  and  the  following  tabulation  serves  only  as  a 
suggestion  of  its  broad  fi(^ld  of  usefulness. 

GENERAL  INDICATIONS 

1.  To  immobilize  and  stimulate  osteogenesis  in  certain 
tuberculous  joints. 

2.  To  repair  traumatic  bone  injuries. 

3.  To  replace  bone  destroyed  by  infection. 

4.  To  supply  bone  congenitally  absent. 

5.  To  strengthen  or  replace  bone  weakened  or  destroyed  by 
benign  or  malignant  growths. 

6.  To  correct  congenital  or  acquired  deformities  of  the  face. 

7.  To  establish  joints  congenitally  absent  and  restore  those 
destroyed  by  disease. 

8.  To  fix  in  place  certain  dislocated  joints  (acquired  or 
congenital). 

9.  To  close  bone  foramina  in  neuralgias. 

10.  To  correct  congenital  or  acquired  deformities  of  extremi- 
ties or  trunk. 

More  specific  indications  for  bone  grafting  are: 

1.  To  immobilize,  support,  and  stimulate  repair  in  spinal 

vertebrae  whose  bodies  are  infected  with  tuberculous  or  other 

chronic  infections  where  mechanical  treatment  is  indicated.     It 

is  also   applicable   in   cases   of  persistent   non-union   following 


FUNDAMENTAL    PRINCIPLES  49 

fracture  of  the  spine,  presenting  pain,  disability,  and  increasing 
deformity,  and  should  be  inserted  as  for  Pott's  disease.  Further 
indications  are  for  certain  fresh  fractures  of  the  spine:  spondy- 
litis traumatica  (Kiimmell's  disease)  and  neuropathic  spine 
(Charcot)  where,  on  account  of  a  rarefying  osteitis,  crushing  of 
the  vertebral  bodies  and  increasing  deformity  is  likely  to  produce 
cord  compression. 

2.  In  the  support  and  immobilization  of  cases  of  tuberculosis 
of  the  sacro-iliac  joint,  in  certain  desperate  cases  of  tuberculosis 
of  the  tarsus,  and  in  the  form  of  inlays  to  hasten  or  insure  bony 
union  in  erasure  or  excision  operations  for  adult  tuberculosis  of 
the  knee  or  hip. 

3.  In  certain  cases  of  paralytic  scoliosis  to  support  the  weak- 
ened spine  and  prevent  lateral  deviation,  due  to  superincumbent 
weight  and  unbalanced  muscle  pull. 

4.  To  immobilize  and  support  or  replace  bones  of  the  tarsus 
destroyed,  or  partly  destroyed,  by  tuberculosis. 

5.  To  correct  deformity  or  restore  balance  in  congenital 
clubfoot  and  acquired  deformity  from  local  disease  or  paralysis. 

6.  As  a  substitute  for  all  metal  plates,  screws,  nails,  spikes, 
and  wires,  as  used  in  the  internal  fixation  of  fractures  and  other 
conditions.  The  graft,  in  the  form  of  inlays  and  various  sizes 
of  nails  or  pegs,  is  employed  by  the  author  in  all  types  of 
fractures,  such  as  fresh  and  ununited  fracture  of  the  long  bones 
and  of  the  neck  of  the  femur. 

7.  To  produce  a  permanent  closure  of  nerve  foramina  after 
nerve  resection  for  neuralgia  (Kanavel). 

8.  As  a  prevention  of  luxating  or  slipping  patellae  by  raising 
the  low  femoral  condyle  by  inserting  a  graft  in  the  form  of  a 
wedge. 

9.  To  aid,  in  the  form  of  numerous  small  grafts,  rapid 
bone  union  where  joint  resection  has  been  done  or  where  a  large 
graft  has  been  used. 

10.  To  strengthen  and  prevent  lordosis  or  other  deformity  of 
the  spine,  in  cases  of  spina  bifida,  where  a  large  amount  of  bone  is 
congenitally  absent. 


50  BONE-(!HAFT    SlUdlOKV 

11.  To  ivi)hi('e  the  heatl  aiul  neck  of  the  lemur,  when  pre- 
\i()usly  destroyed  In'  disease,  the  head  and  neck  of  the  astraga- 
his  l)(>in^  used  as  a  jiraft    (  lloherts). 

12.  Ill  coii-ieiiital  and  jiaralytic  dislocations  of  the  hip  where 
tlu>  acetahuhini  is  sludlow  and  the  femoral  head  will  not  remain  in 
place.  The  uppvv  half  of  the  meagre  rim  of  the  acetabulum  is 
separated  with  a  chisel  and  forced  out  and  down,  forming  a  pro- 
nounced rim.  Tlie  cuneiform  cavity  thus  produced  is  filled 
with  wedge  gi-afts. 

13.  To  produce  an  ankylosis  of  the  ankle  joint  in  severe 
paralj'^tic  cases,  or  tuberculosis  in  the  adult,  by  placing  a  bone- 
graft  peg  through  the  os  calcis  and  astragalus  into  the  lower  end 
of    the  tibia   (Lexer). 

14.  To  replace  bone  removed  for  osteomyelitis,  tul^erculosis, 
and    spina   ventosa. 

15.  For  deformities  of  the  nose,  by  contacting  graft  with  nasal 
bones.  If  the  skin  incision  is  made  in  the  tip  of  the  nose,  the 
scar  is  not  noticeable. 

16.  To  replace  or  repair  defects  of  the  lower  jaw;  to  fill  in 
sunken  spaces  in  the  face,  in  the  forehead  following  operation,  in 
bony  defects  due  to  tuberculous  osteitis  of  the  facial  bones,  in 
recession  of  the  superior  maxilla  due  to  harelip.  To  replace  a 
mastoid  process  removed  by  operation. 

17.  In  intraarticular  fracture-dislocations,  the  head  of  the 
humerus  or  femur,  etc.,  should  be  replaced,  at  an  open  operation, 
as  a  graft. 

18.  To  repair  cavities  in  the  cranial  bones  by  transferring 
from  the  immediate  neighborhood  one  or  two  segments  of  the 
external  table  covered  with  periosteum.  The  cortex  of  the  tibia 
or  a  portion  of  the  scapula  may  likewise  be  used;  the  latter 
source  is  preferable,  as  both  surfaces  of  the  graft  are  covered 
with  periosteum. 

SUMMARY 

The  bone  graft  is  a  trustworthy  surgical  agent,  as  proved  by 
the  author's  uniform  success  in  its  use  in  over  400  surgical  cases; 


FUNDAMENTAL    PRINCIPLES  51 

also  by  a  careful  study  of  its  results,  microscopically,  macro- 
scopically,  and  by  the  X-ray,  when  used  experimentally  in  the 
presence  of  both  primary  union  and  sepsis.  The  field  of  useful- 
ness of  the  cortical  graft  is  distinctly  enhanced  because  of  its 
resistance  to  tubercular  and  attenuated  pyogenic  infection.  Its 
field  is  also  enlarged  by  the  emj^loyment  of  motor-driven  instru- 
ments, circular  saws  of  different  sizes,  the  adjustable  twin  saws, 
and  the  lathe  or  dowel  instrument  with  different  adjustments 
for  making,  as  conditions  demand,  various  sizes  of  bone-graft 
inlays,  nails,  or  spikes.  By  the  use  of  this  motor  outfit  and  its 
products,  in  conjunction  with  kangaroo-tendon,  the  author  has 
been  able  during  the  past  two  years  to  avoid  entirely  the  use  of 
metal  in  the  form  of  screws,  nails.  Lane's  plates,  wire,  etc.,  for 
internal  bone-fixation  purposes.  This  has  been  made  possible, 
largely,  by  utilizing  the  best  of  well-known  mechanical  devices 
hitherto  rarely,  if  at  all,  used  in  surgery — such  as  bone  inlays, 
wedges,  dowels,  tongue  and  groove  joints,  mortised  and  dove- 
tailed joints. 

CONTRAINDICATIONS 

The  only  contraindications  to  the  surgical  use  of  the  bone 
graft  are  a  markedly  septic  field  of  operation  and  excessive  scar 
tissue  as  an  environment.  Syphilis  should  be  cured  before 
operation,  although  one  case  of  syphilitic  osteitis  of  the  spine 
has  been  unintentionally  operated.  The  graft  healed  in  imme- 
diately and  controlled  entirely  the  spinal  symptoms. 


CHAPTER  II 

AUTHOR'S    ELECTRIC    MOTOR    OPERATING    OUTFIT    AND 
TECHNIQUE  OF  USAGE 

Until  1911,  when  the  author  first  began  to  do  his  bone-graft- 
ing oi)oration  for  Pott's  disease,  the  bone  transplant  had  been  so 
infrequently  used  as  a  surgical  agent  that  no  special  technique 
had  been  developed  for  its  removal.  The  electric  motor  circular 
saw  (Doyen)  had  been  used  for  skull  work — driven  by  either  a 
flexible  shaft  from  a  motor  on  a  near-by  stand,  or  by  the  Hartley- 
Kenyon  apparatus,  where  the  cutting  tool  is  attached  directly 
to  the  motor  shaft — and,  so  far  as  the  author  is  aware,  it  had 
not  been  used  in  any  systematic  way  for  the  removal  or  the 
modelling  of  bone  transplants. 

The  author  began  his  spinal  work  by  removing  the  graft 
from  the  tibia  with  chisel  and  mallet,  and  later  others  made  use 
of  the  Gigli  saw.  It  was  soon  found  that  these  methods  were 
not  only  slow  and  inaccurate,  but  that  they  presented  the  dan- 
gers of  bruising,  cracking,  or  fracturing  the  graft  or  tibia,  or 
both.  This  is  especially  true  in  adult  patients,  on  account  of  the 
brittleness  and  thickness  of  the  cortex.  In  the  child,  on  account 
of  the  small  diameter  of  the  bone,  the  danger  of  fracture  is  evi- 
dent, although  the  graft  is  obtained  by  means  of  hand  tools  with 
much  less  difficulty  and  much  less  likelihood  of  fracturing  it. 

Also,  in  obtaining  grafts  8  in.  or  more  in  length,  it  was  found 
that  the  hand-tool  methods  were  crude,  requiring  too  much  time, 
tiring  the  surgeon,  and  unnecessarily  shocking  the  patient.  In 
removing  the  graft  with  the  chisel  and  mallet,  the  graft  must 
many  times  be  handled  and  shaped  after  its  removal,  whereas 
with  the  circular  motor-driven  saw  a  pattern  marked  in  the  peri- 
osteum with  a  scalpel  can  be  followed  accurately  and  the  graft 
shaped  in  situ  during  its  removal.     The  graft  pattern  is  usually 

52 


authoe's  electeic  motoe  outfit  53 

obtained  by  bending  a  flexible  probe  or  leaden  bar  into  the  pre- 
pared graft-bed,  whose  shape  is  transferred  to  the  tibial  surface 
from  which  the  transplant  is  to  be  removed. 

In  modelling  the  graft  into  dowels,  w^edges,  inlays,  and  in 
making  use  of  the  different  well-known  mechanical  devices,  such 
as  tongue  and  groove  joint,  dove-tail  joints,  mortises,  etc.,  the 
motor  outfit  is  still  more  indispensable.  An  accurate  cabinet- 
maker fit  may  mean  success  in  many  instances  where  an  ordinary 
crude  coaptation  would  mean  failure.  Especially  is  this  true 
in  ununited  fractures. 

The  scepticism  as  to  the  value  of  the  graft,  plus  the  difficulty 
in  obtaining  and  moulding  it,  has  undoubtedly  delayed  the 
earlier  development  of  the  use  of  this  most  valuable  surgical 
agent.  It  is  difficult  to  give  an  adequate  reason  why  in  the 
rapid  advance  of  surgery  the  work  of  osteoplasty  has,  until  very 
recently,  stood  for  so  long  a  time  practically  at  a  standstill, 
especially  in  view  of  the  fact  that  Oilier,  in  1858,  from  extensive 
animal  experiments  and  surgical  work — although  working  in 
the  pre-antiseptic  era — furnished  abundant  evidence  that  the 
autoplastic  bone  graft  survived  and  lived  when  consisting  of 
cortex,  periosteum,  and  endosteum,  and  implanted  into  a  bony 
defect  where  it  had  function  to  perform. 

As  in  many  other  fields  of  endeavor,  electric  power  has  been 
the  chief  means  of  placing  this  valuable  agent  at  the  disposal  of 
the  surgeon.  In  recent  years  the  generalization  of  the  use  of 
electricity  for  lighting,  heating,  and  power  purposes  in  most 
hospitals,  private  dwellings,  etc.,  has  also  been  a  potent  influence, 
and  has  enabled  the  surgeon  always  to  be  in  reach  of  the  neces- 
sary power  for  operating  his  motor  outfit — whether  he  is  oper- 
ating in  the  city,  suburban  hospital,  or  private  dwelling.  The 
electric  automobile  or  storage  battery  can  also  be  made  to 
furnish  a  movable  source  of  supply  w^hich  can  be  utilized  at  any 
time  or  place. 

The  ideal  surgical  electro-motor  outfit  should  measure  up  to 
the  following  requirements: 

1.  It  should  permit  of  the  thorough  and  rapid  sterilization 


54  BONE-GRAFT   SURGERY 

of  every  part  which  comes  in  contact  with  the  surgeon  or  the 
field  of  operation,  inchiding  the  electric  cable  for  transmitting 
the  power. 

2.  It  should  permit  of  ready  application  to  all  types  of  osteo- 
plasty, whether  situated  superficially  or  in  a  deep  wound; 
whether  the  work  to  be  done  is  the  procuring  of  the  graft,  the 
preparation  of  its  bed,  the  drilling  of  holes,  the  removal  of  bone 
for  the  correction  of  deformity  or  disease,  or  to  allow  the  proper 
approximation  and  alignment  of  bone  fragments  in  cases  of 
fracture. 

3.  It  should  permit  accurate  control  and  guidance  of  the 
motor  cutting  tool  in  all  wounds  and  at  all  angles. 

4.  It  should  permit  easy  and  convenient  control  of  the  elec- 
tric current. 

5.  It  should  be  light  in  weight,  small  in  bulk,  and  permit  of 
easy  transportation. 

6.  The  motor  should  be  universal  and  adapted  to  all  types 
of  electric  current. 

7.  The  motor  instruments — saws  of  different  types,  drills, 
dowel  shapers,  etc. — should  be  held  in  place  in  the  motor  by  an 
automatic  catch  favoring  their  speedy  interchange. 

8.  The  motor-cutting  tools  should  be  constructed  similarly 
to  those  long-used  by  the  artisan  for  working  hard  materials, 
and  should  be  of  sufficient  variety  to  meet  every  requirement  of 
bone  carpentry.  The  twin  saw  for  inlay  work  should  be  so 
constructed  that  it  can  be  readily  adjusted — to  the  fraction  of 
a  millimetre — by  the  gloved  hands  of  the  surgeon  at  the  oper- 
ating table.  The  dowel  cutters  with  drills  of  corresponding 
diameters  should  vary  in  size  sufficiently  to  meet  all  require- 
ments. 

9.  The  motor  should  furnish  enough  power  to  drive  rapidly 
a  saw  or  large  drill  through  the  thickest  human  cortex  without 
tendency  to  stall. 

The  author's  outfit,  described  in  this  chapter,  has  been  care- 
fully devised  and  perfected  to  fulfil  all  of  the  above-mentioned 
requirements.     The  motor  tool  is  attached  directly  to  the  motor 


author's  electric  motor  outfit  55 

shaft;  the  motor  is  covered  by  an  adjustable  sterihzable  shell, 
enabhng  the  surgeon  to  hold  the  motor  in  his  hands  while  the 
tool  is  cutting;  the  weight  of  the  outfit  has  been  found  to  be  an 
advantage  rather  than  a  detriment  in  its  application,  and  it  is 
believed  that  it  completely  fulfils  every  demand. 

DESCRIPTION  OF  OUTFIT 

The  author's  electric  operating  bone  set  consists  of  a  small 
universal  motor,  i.e.,  one  which  will  operate  without  readjust- 
ment on  all  types  of  electric  currents,  such  as  direct,  alternating, 
and  of  varying  cycles.  If  it  is  to  be  used  on  a  220-volt  direct 
current,  a  100-c.p.  220-volt  lamp  should  be  placed  in  series  with 
motor.  Electrical  engineers  have  found  it  impossible  to  con- 
struct a  light  motor  which  will  resist  deterioration  from  repeated 
boiling  of  the  motor  itself,  or  any  other  safe  type  of  sterilization. 
Both  the  insulating  material  and  the  carbon  brushes  are  liable 
to  disintegration  from  repeated  subjection  to  heat.  There- 
fore, the  Hartley-Kenyon  method  of  removable,  sterihzable 
shells  has  been  adopted,  as  it  seemed  by  all  means  the  most 
desirable. 

The  apparatus  consists  of  a  small  portable  motor  with  a 
sterilizable  shell  which  is  divided  into  two  parts,  so  that  it  can 
be  removed  for  boiling.  A  guide  handle,  which  also  can  be 
boiled,  is  adjusted  at  right  angles  to  the  small  end  of  the  motor 
over  the  shell. 

A  foot  switch  is  supplied  to  make  and  break  the  electric  cir- 
cuit. A  long  electro-conducting  cord  is  provided  to  transmit 
the  current  from  the  source  of  supply.  In  one  end  of  the  cable 
is  a  fitting,  to  be  inserted  into  the  electric  supply,  and  on  the 
other  end  is  a  connection  for  the  foot  switch.  ^Midway  between 
the  two  terminals,  a  connecting  block  is  mounted  into  which  is 
inserted  the  connecting  cord  leading  to  the  operating  motor. 
This  connecting  cord  has  fitted  on  to  one  end  of  it  a  metal  tube 
and  connection  for  the  motor,  and  is  the  only  portion  of  the  elec- 
tric cable  necessary  to  be  boiled. 

The  foot  switch  can  be  used  with  either  side  upward.     If  the 


56 


BONE-GRAFT    SURGERY 


corrup;atod  rubber  side  is  upward,  the  connection  is  made  by 
pushing  down  with  the  foot.  If  the  other  side  is  used  upward, 
the  foot  should  be  placed  over  the  entire  switch,  and  by  depress- 
ing, or  allowing  the  aluminum  lever  to  rise  by  moving  the  heel 


Fig.  13. — Author's  armamentarium  for  bone  work.  1.  Calipers.  2.  Doyen 
washers  or  guards  for  motor  saw.  3.  Spray  and  guard  for  saw.  4.  Twin  saw.  5. 
Dowelhng  instrument  or  lathe.  6.  Right  angle  twin  saw.  7.  Wrenches  for  twin  saw 
and  drill  c-huck.  8.  Drill  witli  guard  to  prevent  it  penetrating  too  deeply.  9.  Drill 
chuck  and  small  drill  in  place.  10.  Burr  for  drilling  fractured  neck  of  femur  for  peg 
graft.  11.  Small  circular  saw.  12.  Large  saw.  13.  Carver's  gouge.  14.  Lowman 
fracture  clamp.  15.  Berg  fracture  clamp.  16.  Wide  osteotome  for  splitting  spinous 
processes  for  the  insertion  of  bone  graft  for  Pott's  disease.  17.  Surgical  electric  motor. 
18.   Compasses.      19.  Lambotte  fracture  clamp,  large  and  small. 

up  and  down,  the  current  is  turned  on  or  off  in  varying  degrees 
and  acts  as  a  speed  regulator  to  the  cutting  tool. 

Cutting  Instruments. — The  single  (circular)  saiv,  about  13^ 
in.  in  diam.,  with  Doyen  graduated  washers  or  guards,  is  used 


author's  electric  motor  outfit  57 

more  than  any  other  of  the  cutting  tools.  These  saws  are  of 
the  best  steel  and  are  very  thin,  and  are  held  on  the  shaft  by 
means  of  nuts  which  allow  the  saw  blades  to  be  changed  when 
they  become  dulled. 

The  twin  saw  is  so  constructed  that  it  can  be  adjusted  to  any 
desired  width,  even  to  the  fraction  of  a  millimetre.  It  con- 
sists of  two  single  saws,  which  can  be  used  singly  or  together. 
Each  saw  is  mounted  on  a  separate  shaft,  one  of  which  is  hollow 
so  that  the  other  shaft  can  be  inserted  into  it  and  so  bring  the 
saws  at  any  distance  apart  that  may  be  desired,  according  to  the 
size  of  the  bone  being  operated  upon  and  the  width  of  the  graft 
or  gutter  to  be  formed. 

In  determining  the  size  of  the  inlay  or  the  gutter,  the  saw 
teeth  are  placed  on  the  exposed  bone  in  the  manner  of  a  compass 
or  calipers  in  order  to  determine  the  width  of  the  inlay  or  gut- 
ter, and,  with  the  saws  undisturbed,  the  shaft  of  the  proximal 
saw  is  prevented  from  turning  by  placing  the  accompanying 
wrench  or  a  heavy  clamp  on  the  flat-sided  end  of  the  shaft, 
while  the  operator  locks  the  saws  together  by  turning  the 
saw  (proximal)  on  this  shaft  away  from  him  protecting  his 
gloved  right  hand  with  a  piece  of  gauze  over  the  saw  teeth. 

The  doivel  instrument  or  latJie  is  fastened  into  the  motor  by 
the  automatic  catch,  precisely  as  are  the  other  cutting  tools. 
Its  speed  of  rotation  is  reduced  about  10  times  by  steel  gears. 

The  size  of  the  bone  graft  dowel  or  nail  is  regulated  by  the 
size  of  the  cutter,  which  is  adjusted  in  the  lathe.  The  largest 
cutter  is  for  turning  out  a  bone  graft  spike  for  a  fracture  of  the 
neck  of  the  femur.  The  smallest  one  is  for  making  pegs  to  hold 
inlay  grafts  in  place.  The  medium-sized  cutter  is  for  making 
graft  nails  for  pinning  the  scaphoid  to  the  head  of  the  astragalus 
in  an  arthrodesis  for  advanced  flat-foot,  or  other  condition. 

The  dowel-shaper  is  used  by  first  inserting  it  into  the  motor, 
and  then  placing  the  apparatus,  parallel  with  and  on  the  edge 
of  the  instrument  table.  While  the  assistant  steadies  the  motor 
and  lathe  by  gently  pressing  the  same  on  the  table,  the  operator, 
holding  with  a  strong  clamp  the  strip  of  bone  to  be  shaped, 


58  BONE-GRAFT   SURGERY 

pushes  it  into  the  dowel-cutter.  When  withdrawn,  it  is  a  per- 
fectly round  dowel,  and  is  ready  to  be  dri\'en  into  the  drill  hole 
made  by  a  drill  of  a  size  corresponding  to  the  dowel-cutter  used. 
The  strip  of  bone  is  obtained  by  means  of  the  single  or  the  twin 
saw. 

The  small  saw  is  used  for  cutting  the  ends  of  the  inlay  graft 
or  the  strip  of  bone  which  is  being  removed  to  produce  a  gutter. 
On  account  of  its  small  diameter  (^4  in.)  the  saw  does  not  en- 
croach into  the  gutter  walls  while  it  is  cutting  across  the  inlay. 

The  guard  with  spray  is  an  important  attachment.  It  is 
connected  by  a  sterile  rubber  tube  with  a  douche  bag  suspended 
over  the  operating  table,  and  maintains  a  constant  spray  of 
saline  solution  on  the  saw,  preventing  friction,  heat,  and  flying 
of  the  solution. 

The  twist  drills  are  of  the  type  used  by  the  machinist  for 
drilling  metal. 

STERILIZATION  (Hartley-Kenyon  Method) 

The  parts  to  be  sterilized  are  first  removed  from  the  motor 
by  releasing  the  plunger  on  the  end  of  the  electric  cable  so  as  to 
allow  it  to  come  out.  This  part  of  the  electric  cable,  from  the 
motor  to  the  black  rubber  union  on  the  contacting  cord,  is 
boiled.  The  handle  and  shells  are  removed  and,  together  with 
the  cutting  tools,  sterilized  by  boiling.  The  part  into  which  the 
cutting  instruments  are  inserted  is  removed  from  the  motor, 
with  the  long  part  of  the  sterilized  shell.  This  is  the  part  which 
contains  the  automatic  catch.  A  little  vaseline  is  placed  in  the 
motor  shaft  opening,  and  the  motor  is  laid  aside  until  the 
sterilizable  parts  are  ready  to  be  readjusted. 

After  sterilization,  the  operator  picks  up  the  long  part  of  the 
shell  with  his  gloved  hand  and  places  it  on  the  corresponding 
end  of  the  motor,  which  the  nurse  holds  with  the  small  end  up. 
(See  Fig.  14.)  The  nurse  holds  the  large  end  of  the  motor  in  the 
palm  of  her  hand  while  the  surgeon  fastens  the  shell  to  the  other 
end  by  turning  the  shell  toward  the  right  as  far  as  it  will  go,  or 


author's  electric  motor  outfit 


59 


until  the  dart  on  the  shell  comes  opposite  the  dart  on  the  motor 
(Fig.  15).  The  operator  can  then  manage  the  motor  alone  by 
grasping  the  sterile  half  shell  which  is  firmly  secured  to  the  motor. 


NON-STERILE- 


Fig.  14. — Method  of  putting  author's  motor  outfit  together.  The  sterile  shell  is 
turned  to  the  left  until  it  can  be  turned  no  further  and  the  arrow  on  the  shell  comes  in 
line  with  the  arrow  on  the  motor.  The  surgeon  then  has  control  of  the  motor  and  turns 
it  over.     (See  Fig.  15.) 

The  second  half  of  the  shell  is  placed  over  the  other  end  of  the 
motor  and  is  locked  in  place  to  the  first  half  shell  by  a  bayonet 
fitting   (Fig.  15).     The  guide  handle  is  placed  over  the  neck 


GO 


liONE-UllAFT    SUKCERY 


of  the  motor  and  securely  fastened  l)y  the  set  screw.  The  con- 
necting plunger  on  the  side  of  the  electric  cable  is  then  inserted 
through  the  sleeve  on  the  shell  into  the  motor.  This  portion 
of  the  electric  cable,  with  its  metal  tube  and  block  connectors, 


STtRlLL 


Fig.   15. — While  the  surgeon  holds  the  motor  by  the  sterile  shell  already  attached,  he 
locks  the  other  half  shell  in  place. 

is  especially  constructed  to  withstand  sterilization  by  boiling. 
The  corresponding  connector  is  next  inserted  into  the  black  con- 
necting block  in  the  central  portion  of  the  cable  leading  from  the 
socket  of  electric  supply  to  the  foot  switch  which  the  nurse  has 


author's  electric  motor  outfit 


61 


Fig.  16. — The  manner  of  holding  the  motor  saw.  The  connecting  wire  to  the  elec- 
tric wall  fixture.  The  foot  switch  control.  The  sterilizable  connecting  wire  _  to  the 
motor.  The  sterilized  rubber  tube  connecting  the  tank  of  normal  saline  solution  and 
the  spray  attachment  above  the  saw  are  shown.  The  author's  broad  thin  osteotome  for 
splitting  the  spinous  processes  and  the  calipers  for  determining  the  length  of  the  graft 
are  on  the  instrument  table. 


()2 


KONE-GKAFT    SUHGEHY 


previously  connected  and  arranged  witli  the  foot  switch  in  a 
convenient  position  for  the  surgeon's  controlling  foot  while  he 
is  operating.  The  motor  is  then  ready  for  use.  The  saws  or 
the  cutting  tools  are  inserted  by  turning  them  over  a  little  to 
the  right  or  the  left  while  the  knurled  ring  on  end  of  the  shaft 


^^. 


Fig.   17. — Martel's  attachment  to  author's  electrical  surgical  outfit  for  laminectomy 

and  skull  work. 

is  pressed  in  by  the  operator's  thumb,  or  until  the  spring  en- 
gages the  slot  on  the  side  of  the  shaft  of  the  instrument.  The 
cutting  tool  is  unlocked  by  pressing  the  knurled  ring  on  the  end 
of  the  shaft  at  the  same  time  that  the  instrument  is  withdrawn. 


Fig.   18. — Martel's  attachment  to  author's  electrical  surgical  outfit  for  skull  work. 

The  action  of  the  motor  is  controlled  by  the  foot  switch  which 
makes  and  breaks  the  electric  circuit,  and  the  surgeon  thus  has 
the  uninterrupted  use  of  both  hands  and  the  most  precise  speed 
control  of  the  cutting  instruments. 

This  automatic   control  is  a  great  improvement  over   the 


author's  electric  motor  outfit  63 

screw  and  screw-driver  arrangement  for  holding  the  cutting 
instruments  as  used  on  the  Hartley-Kenyon  motor.  In  certain 
plastic  work,  especially  fracture  work,  it  may  be  necessary  at 
one  operation  to  employ  several  different  cutting  tools,  such 
as  two  sizes  of  single  saws,  tw4n  saw,  different  sized  drills,  and 
surgical  lathe,  and  also  to  interchange  these  several  times. 
The  automatic  catch  permits  of  almost  as  speedy  a  change  of 
motor  tool  as  of  hand  instruments,  and  is  a  most  important 
feature  of  the  outfit.  As  far  as  the  author  is  aware,  this  is  the 
first  automatic  catch  to  be  incorporated  into  an  electric-motor 
surgical  outfit,  and  it  is  almost  indispensable  to  rapid  work. 
Then,  again,  the  screw-driver  is  a  source  of  danger  to  the  opera- 
tor's gloved  hand,  because  while  loosening  or  tightening  the 
screw,  the  motor  shaft  may  turn,  allowing  the  screw-driver  to 
push  by  and  puncture  the  surgeon's  glove. 

TECHNIQUE  OF  USING  MOTOR 

When  the  motor  tool  is  cutting,  the  handle,  which  is  placed 
at  a  right  angle  to  the  long  axis  of  the  motor,  is  held  in  the 
operator's  right  hand;  the  base  of  the  motor  is  grasped  in  the 
left  hand,  and  the  right  foot  manipulates  the  foot  switch,  which 
is  placed  on  the  floor  beside  the  operating  table,  at  a  place  con- 
venient for  the  operator's  foot.  If  found  necessary,  the  position 
of  the  motor  and  the  hands  may  be  reversed.  The  various 
technical  apphcations  of  the  outfit  will  be  illustrated  in  detail  in 
the  various  special  chapters. 


CHAPTER  III 

THE  BONE  GRAFT  IN  THE  TREATMENT  OF  POTT'S  DISEASE 
AND  OTHER  LESIONS  OF  THE  SPINE 

Pott's  disease  was  so  called  from  the  fact  that  Percival  Pott, 
in  1779,  was  the  first  to  describe  accurately  this  slowly  develop- 
ing deformity,  accompanied  by  pain  and  at  times  by  paralysis. 


Fig.   19. — A  case  of  Pott's  disease  in  a  young  man  of  17  years,  after  10  years  of  plaster- 
of-Paris  jacket  treatment.     The  marked  compression  of  the  thorax  is  very  striking. 

He  did  not,  however,  ascertain  its  cause,  and  it  was  not  until 
1882  when  Robert  Koch  made  his  discovery  of  the  tubercle 
organism  that  its  etiology  was  definitely  determined.  ^ 

64 


pott's  disease  and  other  spinal  lesions  65 

At  the  present  time  the  term,  instead  of  inckiding  the  various 
causes  of  angular  deformity,  such  as  may  be  the  result  of  frac- 
ture, malignant  disease,  erosion  of  an  aneurism,  syphilis,  or  other 
pathological  process,  is  confined  to  those  cases  of  kyphosis  where 
the  deformity  is  due  to  a  tuberculous  infection  of  the  bodies  of 


Fig.  20.- — Rontgenogram  of  a  case  of  Pott's  disease  of  the  spine  showing  extreme 
rarefaction  of  the  wedge-shaped  mass  of  bone  detritus  at  A,  which  has  resulted  from 
the  disintegration  and  crushing  of  two  vertebral  bodies,  during  plaster-jacket  treatment, 
although  there  has  been  a  large  destruction  of  bone  there  has  been  no  coincident 
proliferation  of  osseous  tissue. 

This  factor  is  largely  responsible  for  the  striking  tendency  to  progression  of  disease 
and  deformity  in  spite  of  conservative  treatment,  and  is  at  the  same  time  a  strong 
argument  in  favor  of  the  bone-graft  instrument. 

the  vertebrae.  The  compression  and  disintegration  of  these 
vertebral  bodies  produces  the  characteristic  angular  deformity 
of  Pott's  disease. 

As  the  structure  of  the  bodies  of  the  vertebrae  is  made  up 
almost  entirely  of  spongy  bone,  and  as  tuberculous  disease  in 


66 


BONE-GRAFT    SURGERY 


bone  is  confined  almost  entirely  to  this  cancellous  bone  struc- 
ture, it  follows  that  this  portion  of  the  vertebra  is  involved 
to  the  exclusion  of  the  denser  or  cortical  portion,  i.e.,  the  lateral 
masses  and  si)iiu)us  processes. 

As  the  action  of  each  vertebra  in  the  spinal  column  is  for 
the  most  part  a  leverage  action,  and  as  the  superincumbent  body 


<-C 


Fig.  21. — Rontgenogiam  of  the  dorso-lumbar  spine  showing  the  bodies  of  the  verte- 
brae B  and  C  completely  obliterated  and  one  directly  above  and  below  thinned  and 
wedge  shaped  due  to  the  tuberculous  process. 

The  resulting  kyphotic  angle  of  the  spine  thus  produced  should  be  noted. 

The  principal  feature,  however,  of  this  rontgenogram  as  in  Fig.  20  is  that  no  repair 
by  bone  proliferation  is  shown,  although  the  destructive  lesion  in  this  case  had  existed 
for  not  less  than  3  j^ears.     The  need  of  the  implantation  of  bone  is  apparent. 


weight  is  borne  in  very  large  measure  by  the  individual  bodies 
of  the  vertebral  column  with  their  interposed  intervertebral 
cartilaginous  discs,  it  follows  that  as  respiratory  action  and 
involuntary  contraction  of  the  abdominal  muscles,  together  with 


pott's  disease  and  other  spinal  lesions 


67 


the  activity  of  the  tuberculous  focus,  weakens  the  resistance  of 
the  bodies  to  weight-bearing,  these  bodies  are  crushed,  and  unless 
measures  are  taken  to  prevent  this  crushing  and  transfer  the 
weight-bearing  more  upon  the  articular  processes  and  lateral 


Fig.  22. — A  c;isu  of  iufcciiuu.s  o.stiti.s  uf  the  luiiibar  .^piuc.  The  arrows  indicate  the 
large  amount  of  new  bone  formation  which  is  in  such  marked  contrast  to  the  absence  of 
bone  proliferation  in  tuberculosis  of  the  spine.  Ultimate  telescoping  of  the  veretebral 
bodies  can  be  prevented  in  such  cases  by  conservative  splint  treatment  because  of  the 
active  bone  proliferation. 

masses,  this  crushing  effect  continues  and  the  vertebral  column 
collapses  forward  at  the  expense  of  the  anterior  arms  of  the 
levers  (the  vertebral  bodies) ,  causing  a  separation  of  the  posterior 
arms  of  the  levers  (the  spinous  processes),  thus  producing  the 


68 


BONE-GRAFT   SURGERY 


increasing  angular  deformity,  or  kyphosis,  so  noticeable  in  these 
cases. 

Various  procedures  have  been  adopted  on  the  basis  of  this 
principle  of  the  leverage  action  of  the  vertebrae  in  order  to 
prevent  the  increase  of  this  posterior  angular  deformity.  The 
arrest  of  the  tuberculous  process  depends  upon  the  ability  to 
check  this  increasing  kyphosis  and  prevent  further  collapse 
of  the  vertebral  bodies.  As  can  be  readily  seen,  any  external 
fixation  applied  to  the  series  of  levers  of  the  spine  as  a  whole 


Fig.  23. — Acute  Pott's  disease,  with  an  angular  kyphosis  and  much  respiratory 
motion  between  the  vertebrce  of  the  gibbus.  This  was  partially  straightened  and  a  graft 
inserted.     (See  Fig.  24.) 

cannot  be  so  exact  in  its  control  of  any  segment  thereof  as  a 
fixation  applied  directly  to  the  leverage  action  of  the  particular 
vertebrae  involved.  Thus,  we  can  compare  the  inexactness  of 
the  plaster  jacket  with  the  direct  fixation  of  the  bone  graft. 

The  means  adopted  to  bring  about  this  arrest  of  increasing 
deformity  also  relieve  the  other  symptoms  accompanying  the 
disease — pain,    involuntary    muscle-spasm,    general    weakness 


pott's  disease  and  other  spinal  lesions  69 

and  the  characteristic  awkwardness  of  attitude.  The  methods 
heretofore  employed  to  accompHsh  this  have  been:  (1)  Re- 
cumhency,  which  removes  one  of  the  chief  exciting  factors, 
namely,  the  superincumbent  weight  of  the  body.  This  must 
be  maintained  during  the  activity  of  the  destructive  process. 
(2)  The  application  of  plaster-of -Paris  jackets  or  braces,  either  as 
a  further  means  of  fixation  following  the  months  of  compulsory 


Fig.   24. — Same    case    as    Fig.    23.     Two  years  after  correction  and  insertion  of  graft. 

recumbent  treatment  on  a  gas-pipe  frame  or,  as  it  is  employed 
by  many,  in  conjunction  with  a  certain  amount  of  rest  in  the 
recumbent  posture  from  the  time  the  lesion  is  discovered — the 
so-called  ambulatory  treatment. 

Nature,  in  her  endeavor  to  protect  the  spine  when  attacked 
by  tuberculosis,  resorts  to  immobilization  of  the  diseased  area 
by  the  means  at  her  command,  and,  by  fixing  the  attached  spinal 
and  abdominal  muscles  in  involuntary  spasm,  accomplishes  this 


ro 


BONE-GRAFT    SURGERY 


immobilization  to  a  certain  decree,  but  in  so  doing  increases 
the  crushing-  effect  of  the  diseased  vertebral  bodies  with  in- 
creasing collapse  of  the  spine,  which  together  with  the  added 
influence  of  respiratory  motion  usually  results  in  extensive 
kyi)hosis  and  disability. 


Fig.  25. — A  result  of  10  years  of 
conservative  treatment,  including  Ij-^ 
years  on  gas-pipe  frame  and  83^  years 
of  plaster-of-Paris  jackets.  A  spinal 
support  was  still  necessary. 


Fig.  26. — Case  of  acute  Pott's  disease 
operated  during  the  first  year  of  the  dis- 
ease when  there  was  a  very  small  kyphosis. 


As  nature  has  taught  us  that  immobilization  is  the  prime 
factor  in  arresting  tuberculous  osteitis,  we  have  endeavored  to 
substitute  for  nature's  method  our  artificial  fixation  in  an  at- 
tempt to  prevent  the  disfiguring  and  crippling  angular  deformity 
and  progress  of  the  disease;  but  as  in  conservative  brace  methods 
w^e  had  the  means  only  approximately  to  accomplish  this  end, 


pott's  disease  and  other  spinal  lesions  71 

many  cases  continued  to  develop  increasing  deformity  and  com- 
plete invalidism  and  succumbed  to  this  debilitated  state. 

It  is  the  exception  and  not  the  rule  for  cases  of  Pott's  disease 
treated  by  the  conventional  methods  of  externally  applied 
fixation  to  produce  a  solid  bony  union,  and  when  actual  firm 
bony  fixation  is  not  accomplished  the  case  cannot  be  considered 
cured. 


Fig.   27. — Same  case  as  Fig.  26.     Shows    function  of  spine  2  years  after  operation 
The  arrow  indicates  location  of  graft. 

These  joints,  like  other  joints  of  the  body  attacked  by 
tuberculosis  where  only  fibrous  union  has  taken  place,  are 
always  liable  to  a  relapse.  As  has  been  pointed  out  by 
many  men  dealing  with  tuberculous  osteitis,  it  is  always  essen- 
tial to  secure  a  strong  bony  ankylosis  in  order  to  arrest  and 
cure  tuberculous  lesions  where  actual  bone  destruction  has 
taken  place.  This  rule  applies  even  more  strongly  to  the 
vertebral  joints  of  the  spine. 

With  such  examples  of  ineffectual  control  of  this  progressive 


72 


BONE-GRAFT   SURGERY 


tuberculous  disease  constantly  in  evidence,  further  efforts  were 
made  to  provide  more  accurate  fixation  of  the  tuberculous  spine. 
Appreciating  the  leverage  action  of  these  vertebra)  and  failures 
to  arrest  the  disease  by  external  appliances,  actual  surgical  inter- 
vention by  wiring  together  the  spinous  processes  of  the  diseased 
vertebrae  with  silver  was  tried;  but  as  silver  wire  stands  very 


Fig.  28. — Photograph  of  acute  case  of  Pott's  disease  before  insertion  of  bone   graft. 

little  strain,  this  wiring  breaks,  or,  being  a  foreign  material, 
it  causes  absorption  of  the  bony  structure  in  which  it  is  placed 
and  pulls  through  and  drops  out  by  its  own  weight,  and  so  loses 
its  value;  or  infection  takes  place  and  the  resultant  necrosis 
neutralizes  any  possible  benefit. 

Lange,  in  1910,  presented  before  the  American  Orthopaedic 
Association  a  method  which  he  had  tried,  which  consisted  in 


POTT  S    DISEASE    AND    OTHEK    SPINAL    LESIONS 


73 


placing  a  metal  bar  on  either  side  of  the  spinous  processes, 
secured  by  metal  or  silk  sutures.  This  method  has  not  been 
adopted,  undoubtedly  because  of  reasons  similar  to  those  given 
for  the  failure  of  the  silver  wire  fixation  of  the  vertebra.  Never- 
theless, the  suggestion  was  offered  that  if  some  means  could 
be  provided  for  rendering  the 
posterior  arms  of  the  vertebral 
levers  more  accurately  fixed,  a 
consequent  arrest  of  the  increas- 
ing deformity  and  disability 
could  be  rendered  more  certain. 

In  the  folder  of  the  American 
Orthopaedic  Association  pub- 
lished May  15,  1911,  and  distrib- 
uted to  its  members,  the  author 
described  a  method  of  ankylos- 
ing together  the  spinous  proc- 
esses of  tuberculous  infected 
vertebrae  by  autogenous  osteo- 
plasty, which  seemed  to  offer  ad- 
vantages over  the  methods  pre- 
viously employed,  conservative 
or  operative. 

The  technique  employed  upon 
four  cases  consisted  in  splitting 
the  spinous  processes  longitudi- 
nally in  halves,  fracturing  these 
halves  at  their  bases,  freeing 
them  of  ligamentous  and  muscu- 
lar attachments,  turning  one-half 
down  to  contact  with  the  frac- 
tured base  at  the  fractured  half  of  the  spinous  process  below, 
and  turning  up  the  other  half  to  contact  with  the  base  of  the 
fractured  half  of  the  spinous  process  above,  and  so  on  until 
a  sufficient  number  of  spinous  processes  had  been  so  dealt  with 
as  to  include  the  entire  area  of  the  diseased  vertebrae  and  ex- 


FiG.  29. — Same  case  as  Fig.  28. 
Eight  months  after  bone-graft  opera- 
tion.    Function  excellent. 


74 


BONE-GRAFT    SURGERY 


tend  above  and  below  to  include  a  healthy  vertebra.  Practi- 
cally the  whole  spinous  process  is  covered  with  ligamentous  and 
muscular  attachments,  consequently  there  is  very  little  actual 
periosteum  obtainable. 


^P 


Fig.  30. — Rontgenogram  of  a  case  of  Pott's  disease  showing  two  vertebral  bodies 
crushed  into  a  thin  wedge  shape  mass  less  in  thickness  than  one  normal  vertebral 
body.  The  resulting  kyphosis  is  clearly  demonstrated.  (See  Fig.  31,  after  implantation 
of  the  graft.) 

In  these  cases,  which  were  all  children,  this  ligamentous 
covering,  together  with  what  periosteum  was  found,  was 
separated  off  these  spines  and  sutured  over  and  about  the 
arranged  split   fragments   of  the   spinous   processes.     In  this 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


75 


way,  an  attempt  was  made  to  ankylose  together  the  posterior 
segments  of  these  vertebrae  and  thus  actually  to  inhibit  all  inter- 
vertebral motion  from  respiration  or  muscle  action,  and  finally 
to  stop  the  further  crushing  together  of  the  diseased  bodies  of 
these  vertebrae. 


Fig.  31. — Lateral  rontgenogram  of  a  bone  graft  {ab)  in  place  1  year  for  tuberculo- 
sis of  the  second,  third  and  fourth  lumbar  vertebrse;  cd  indicates  the  bone  repair  and 
fusion  of  the  formerly  diseased  vertebral  bodies,  induced  by  the  bone-graft  fixation 
(See  Fig.  30.) 

Since  this  method  consumed  much  operative  time  and  in- 
volved dealing  with  a  number  of  small  pieces  of  bone  which 
had  to  be  secured  in  a  position  favorable  to  final  bony  anky- 
losis, and  as  there  was  an  element  of  uncertainty  (on  account 
of  constant  uncontrollable  respiratory  motion)  in  bringing 
about  this  desired  ankylosed  condition  of  all  these  segments  of 


7G 


BONE-GRAFT    SUHGEKY 


bone — a  failure  to  produce  this  ankylosis  between  any  two  given 
vertebrie  necessarily  producing  a  failure  in  the  ultimate  result — 
the  author  was  further  influenced  to  change  the  method  on  account 
of  the  meagre  amount  of  osteogenetic  bone  present  in  the  spinous 
processes  (especially  in  children,  where  it  is  largely  in  a  cartilagi- 


FiG.  32. — Pott's  disease  of  last  lumbar  vertebrae  and  first  segment  of  sacrum  in  a 
young  woman  of  28  years.  A  mistaken  diagnosis  led  to  previous  removal  of  most  of 
the  pelvic  viscera  for  pelvic  pain.  Patient  was  then  placed  on  a  plaster-of-Paris  bed 
for  1  year  for  Pott's  disease.  At  the  end  of  this  time  patient  was  allowed  up  with  a 
long  spinal  brace.  A  relapse  of  her  old  symptoms  with  a  threatening  paraplegia 
occurred  in  a  few  weeks.  A  well-known  orthopifidic  surgeon  advised  another  year  on 
a  plaster  bed,  was  refused  and  the  graft  AB  was  inserted  2  years  ago  with  continued 
relief  of  all  symptoms  to  date. 


nous  state)  and  to  adopt  the  much  simpler  bone-graft  method  now 
employed,  which  has  given  extremely  satisfactory  results. 

This  consists  in  the  implantation  of  one  continuous  strip  of 
bone  (removed  preferably  from  the  tibia)  sufficiently  long  to 
span  the  diseased  vertebrae  and  include  one  or  two  healthy 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


77 


vertebrae  above  and  below  those  involved  in  the  tuberculous 
infection.  This  tibial  bone  graft  is  implanted  in  a  gutter 
previously  made  by  splitting  the  spinous  processes  to  receive 
this  long  graft  of  bone  between  their  split  halves. 

As  broken  or  incised  cartilage  tends  to  heal  by  the  formation 


Fig.  33. — Author's  broad  thin  osteotome  for  splitting  the  spinous  processes  of  the  spine 
in  preparing  the  graft  bed. 

of  bony  callus,  and  as  the  implantation  of  a  bone  graft  into 
cartilage  also  influences  the  surrounding  cartilage  to  immediately 
change  to  bone,  the  increased  trustworthiness  of  the  bone  graft 
(especially  in  small  children),  as  compared  with  the  previous 
osteoplasty,  is  apparent. 


78 


BONE-GRAFT    SURGERY 


The  detailed  steps  of  the  technic^ue  of  preparing  the  graft 
bed,  together  with  the  removal  of  a  suitable  graft  and  its 
implantation,  as  carried  out  by  the  author,  is  as  follows  (and 
this  applies  in  a  general  way  to  its  use  in  the  different  segments 
of  the  spine) : 

The  patient,  having  been  prepared  for  operation  in  the  usual 
way,  is  placed  prone  upon  the  operating  table,  and  a  general 
anaesthetic  is  administered.  The  region  of  the  spine  included 
in  the  field  of  operation  is  sterilized,  as  well  as  the  leg  from 
which  the  graft  is  to  be  obtained.  The  author  uses  the  iodine 
method. 


B 

Fig.  34.  Fig.  35. 

Fig.  34." — Drawing  of  cross-section  of  tibia.  A  is  spinal  graft  for  an  early  case  that 
has  not  become  kyphotic.  B  is  cross-section  of  graft  which  on  account  of  the  large  size 
of  the  kyphosis  is  bent  over  it.     D  represents  the  multiple  saw  cuts  on  the  marrow  side. 

Fig.  35. — A  illustrates  a  cross-section  of  a  spinous  process  split  in  half  and  fractured 
at  its  base.  The  deep,  thin  graft  in  cross-section  has  been  removed  from  the  crest  of 
the  tibia  having  its  periosteum  attached  to  two  sides.  The  side  in  contact  with  the 
unbroken  half  of  the  spinous  process  is  the  saw  cut  or  the  medullary  surface  of  the 
graft. 

B  illustrates  a  cross-section  of  a  spinous  process  which  has  been  split  and  one-half 
has  been  set  over  to  produce  a  gap  sufficient  to  receive  a  broad  graft  removed  from  the 
antero-internal  surface  of  the  tibia  having  periosteum  on  one  surface  only;  the  medul- 
lary surface  of  the  graft  lies  nearest  the  base  of  the  spinous  process  in  the  gap. 

Author's  Operative  Technique. — A  sufficiently  long  skin  in- 
cision is  made,  starting  well  above  the  diseased  area  and  swerving 
to  one  side  of  the  midline,  and  carried  back  to  the  midline  well 
below  the  affected  area,  thus  forming  a  semilunar  skin  flap 
with  its  border  well  away  from  this  midline  to  avoid  having  the 
skin  wound  directly  over  the  bone  incisions  and  graft,  thus 
fortifying  the  grafted  area  should  any  skin  or  suture  infection 
take  place. 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


79 


Having  dissected  up  this  skin  flap  with  its  subcutaneous 
structure,  the  tips  of  the  spinous  processes,  with  the  supra- 
spinous ligaments,  are  exposed.  As  no 
important  vessels  are  encountered  in 
this  region,  hemorrhage  is  of  slight  con- 
sequence. If  need  be,  the  bleeding 
points  may  be  clipped  and  tied  off,  but 
a  hot  saline  compress  is  usually  sufficient 
to  control  any  undue  oozing  and  prevent 
large  blood-clots  from  forming.  A  cer- 
tain amount  of  serous  exudate  and  blood 
is  considered  advantageous  to  early  fixa- 
tion of  the  grafted  area. 

With  a  scalpel,  the  supraspinous 
ligament  is  split  over  the  tips  of  the 
spinous  processes,  dividing  them  into 
equal  halves;  the  interspinous  ligaments 
are  also  split,  care  being  exercised  fur- 
ther not  to  sever  any  of  the  muscle  or 
ligamentous    attachments    to    these 

.  .  Fig.  36.— Each   vertebra 

spinous       processes.        Then,       with       the    is    a    lever   with    its   fulcrum 

author's  broad   thin    sharp    osteotome, 
13^^  in.  wide  (made  by  Tiemann  &  Co. 

of   New  York),  the  spinous  processes  are    muscle   spasm,    etc.,   influenc- 
ing     crushing      of      vertebral 
split    to    a    depth,    usually,    of    from    one-    bodies  and  progress  of  deform- 
.  1  •     1      .         .  J 1  •     1  c  •       1  r\  ity   by   the   approximation   of 

third    to    tWO-thn-ds    Ot     an    inch.       One-    the       anterior      lever      arms. 

half  of  each  spinous  process,  always  on  "^  ".epTatlon^  ot'Nhe 

the    same    side,    is    fractured    completely    spinous  processes  or  the  pos- 
terior    lever    arms.      This     is 

at  its  base  and  set  over  a  distance  vary-  prevented  by  a  puU  length- 

T  .         ji  ji'i  n     ,  1         wise  on  the  graft  as  indicated 

mg    according     to    the    thickness    of    the    by  the   small  arrows  situated 

graft   which    is   to   be   implanted.     All  ^t  each  spinous  process.    The 

°  ^  graft  in  respect  to  this  direc- 

bleeding  points  are  ligated   or   checked  tion  of  force  is  under  a  great 

mechanical  advantage. 

by  hot  saline  compresses. 

It  necessarily  rests  with  the  operator  to  determine  the  size 
and  thickness  of  the  graft  required,  taking  into  consideration 
the  segment  of  the  spine  to  be  grafted  and  the  amount  of  strain 


point  at  small  F.  The  arrow 
on  the  vertebral  bodies  at  2, 
2,  indicates  lines  of  force  from 
weight     bearing,    involuntary 


80 


BONE-GKAFT   SURGERY 


the  graft  must  endure.  In  general,  the  thickness  of  the  graft 
should  include  the  total  thickness  of  the  tibial  cortex,  including 
periosteum,  endosteum,  and  marrow  substance. 

The  graft  bed  now  prepared  presents  on  one  side  of  the 
gutter  the  incised  surfaces  of  the  unbroken  halves  of  the  spinous 
processes,  and  in  the  intervals  between  these  processes  are  the 
cut  surfaces  of  the  halves  of  the  supraspinous  and  interspinous 
ligaments  with  their  osseous  attachments  undisturbed.  The 
opposite  wall  of  this  gutter  is  formed  by  the  incised  surfaces  of 
the  fractured  halves  of  the  spinous  processes,  with  their  portions 


Fig.  37. — The  flexible  probe  bent  to  conform  to  the  spinal  kyphosis  and  used  as  a 
pattern  in  removing  the  curved  graft  from  the  antero-interual  surface  of  the  tibia  if 
the  spine  is  not  suitable  to  be  straightened. 

of  supra-  and  interspinous  ligaments  undisturbed,  as  in  the  oppo- 
site side  of  the  gutter.  This  leaves  the  muscle  and  ligamentous 
attachments  intact,  save  for  the  splitting,  fracturing,  and 
spreading  on  one  side  of  the  spinous  process  halves  with  their 
attached  ligaments.  In  other  words,  the  antero-posterior  diam- 
eter of  the  spinal  column  has  not  been  diminished  or  weakened 
to  any  degree  by  the  preparation  of  the  graft  bed.  The  full 
leverage  of  the  spinous  processes,  as  posterior  arms  of  vertebral 
levers,  has  been  preserved. 

In  this  connection,  it  should  be  appreciated  that  the  spine 
is  made  up  of  a  series  of  levers,  and  that  each  A^ertebra  is  an  in- 
dividual lever  with  its  fulcrum  at  the  lateral  facets,  and  that  its 
anterior  arm  is  the  vertebral  body,  the  posterior  arm  being 
the  spinous  process. 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


81 


The  length  and  shape  of  the  required  graft  is  determined  by 
cahpers  and  a  flexible  probe  applied  to  the  gutter-bed.  The  whole 
denuded  field  is  packed  with  a  hot  saline  compress  until  the  next 


Fig.  38. — To  illustrate  method  of  applying  force  to  straighten  spine,  at  the  same  time 
that  the  contour  of  the  corrected  kyphosis  is  obtained  with  flexible  probe  for  purpose  of 
pattern  for  removal  of  graft  from  tibia.      (See  Fig.  37.) 

step  is  completed,  namely,  the  removal  of  the  graft  from  the 
tibia. 

Removal  of  Graft. — With  the  patient  still  in  the  prone  posi- 
tion on  the  operating  table,  the  leg  from  which  the  graft  is  to 


Fig.  39. — Actual  contour  of  flexible  probes,  bent  into  tips  of  spinous  processes  be- 
fore and  after  forcible  correction.  A  is  before  correction.  B  after  correction.  (See 
Figs.  37  and  38.) 

be  removed  is  raised  from  the  table  and  flexed  to  an  acute  angle 
on  the  thigh.     A  skin  incision  is  made  along  the  antero-internal 


82 


BONE-GRAFT   SURGERY 


Fig.  40. — The  flexible  probe  bent  to  conform  to  the  spinal  kyphosis  and  applied  to 
the  antero-internal  surface  of  the  tibia,  held  by  a  foreep  while  the  shaped  graft  is  being 
outlined  in  the  periosteum  by  the  scalpel  prior  to  the  removal  by  the  motor  single  saw  of 
the  graft  thus  outlined. 

The  centre  of  the  graft  angle  includes  the  crest  of  the  tibia  thus  strengthening  its 
centre. 

The  ends  of  the  graft  include  the  cortical  surface,  the  full  thickness  to  the  marrow 
cavity  on  the  antero-internal  surface. 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


83 


surface  of  the  tibia,  sufficiently  long  to  allow  a  generous  exposure 
of  the  tibia  for  the  removal  of  the  graft,  and  so  placed  that  its 
closure  will  not  bring  the  skin  sutures  over  the  bone  cavity 
produced  by  the  removal  of  the  graft.  The  skin  is  dissected 
up  from  the  periosteum,  which  is  left  undisturbed,  and  the 
muscles  attached  to  the  crest  of  the  tibia  are  freed.  The  pattern 
of  the  required  graft  is  outlined  by  incising  the  periosteum  with 
a  scalpel,  using  the  moulded  probe  as  a  pattern  rod.  The  graft 
is  best  taken  from  the  lower  three-fourths  of  the  antero-internal 
surface,  as  this  portion  of  the  tibia  is  usually  sufficiently  broad 
and  furnishes  a  cortex  denser  and  stronger  than  the  upper  portion 
of  the  bone. 

If  the  graft  is  to  be  straight,  it  is  best  removed  from  the 
crest,  wide  enough  to  encroach  upon  the  antero-internal  surface, 


Fig.   41. — The  outline  in  the  periosteum  on  the  antero-internal  surface  of  the  tibia  of 
the  curved  bone  graft  for  the  operative  treatment  of  Pott's  disease. 

so  as  to  furnish  the  width  required.  If  the  graft  is  to  be  moulded 
for  a  moderate  kyphosis,  the  pattern  probe  is  so  applied  to  the 
antero-internal  surface  of  the  tibia  that  the  central  or  fulcrum 
portion  of  the  curved  graft  includes  the  crest  of  the  tibia  and 
each  end  is  cut  obliquely  across  the  antero-internal  surface  (see 
drawing,  Fig.  40).  The  advantage  of  the  graft  thus  obtained 
is  that  it  includes  at  its  fulcrum  portion  the  dense  and  thick 
cortical  bone  of  the  crest.  This  is  important,  because  the 
strength  of  any  lever  is  dependent  upon  the  strength  of  its 
fulcrum  portion  {a,  b,  Fig.  41). 

It  has  been  found  that  kyphoses  sharply  angular  and  of  short 
duration,  especially  in  children,  are  amenable  to  varying  de- 
grees of  correction,  which  fact  can  be  taken  advantage  of  in 
moulding  the  graft  to  conform  to  this  amount  of  correction. 


84 


BONE-GRAFT    SURGERY 


After  preparino-  the  gutter  bed,  the  spine  is  corrected  by  manual 
pressure  on  either  side  over  the  lateral  masses,  while  the  contour 
of  the  spine  thus  corrected  is  obtained  by  bending  the  probe  into 
the  clefts  of  the  split  s])iii()us  ])i-()cesses.  The  technicpie  is  carried 
out  precisely  as  described  above,  except  for  the  addition  of  the 
correction  pressure  while  the  kangaroo  sutures  are  lieing  placed 
to  secure  the  graft  in  position. 

The  straight  graft  is  obtained  by  cutting  the  tibial  cortex 
through  to  the  mari'ow  cavity  with  the  motor  circular  saw, 
following  the  periosteal  outlines  already  made;  this  includes  a 
saw-cut  just  to  the  outer  side  of  the  tibial  crest  and  at  a  right 


Fig.  42. — Moulded  graft  for  Pott's  disease  in  place  with  the  kangaroo-tendon  sutures  in 

process  of  being  inserted. 

angle  to  the  one  previously  made  on  the  antero-internal  surface. 
This  cut  must  be  made  the  whole  length  of  the  graft,  if  a  straight 
one;  and,  if  a  moulded  one,  only  to  include  the  middle  or  fulcral 
portion.  At  either  end  beyond  this  central  or  crest  portion  the 
graft  overlies  the  marrow  cavity  and  the  saw-cuts,  therefore,  need 
only  to  come  on  the  antero-internal  surface  of  the  tibia. 

At  the  ends  of  the  graft,  saw-cuts  are  made  with  a  very  small 
motor  saw,  to  finish  freeing  the  graft  from  the  tibia.  It  is  then 
loosened  by  a  thin  osteotome  introduced  into  the  longitudinal 
saw-cuts  and  pried  free.  The  motor  saw  is  not  absolutely 
necessary  for  the  removal  of  the  graft,  since  thin  chisel  or  osteo- 


POTTS    DISEASE    AND    OTHER    SPINAL    LESIONS 


85 


tome  and  a  mallet  serve  the  purpose  and  certain  opera- 
tors have  continued  to  remove  the  graft  in  this  way.  In 
adults,  the  motor  saw  has  a  distinct  advantage,  as  the  bone 
is  very  dense  and  brittle  and  if  the  chisel  and  mallet  are  used 
it  requires  the  greatest  care  on  the  part  of  the  operator  to  avoid 
cracking  the  graft  or  the  remaining  portion  of  the  tibia.  The 
method  is  not  only  slow,  but  the  constant  blows  of  the  mallet 
on  the  chisel  traumatize  the  graft  and  does  not  allow  its  accurate 
moulding.  Pain  in  the  leg  has  also  been  observed  to  be  less  since 
the  motor  outfit  has  been  perfected  for  this  use. 

After  the  graft  is  freed  it  is  seized  by  clamps,  and  placed 
in  the  bed  previously  prepared  for  its  reception,  thus  avoiding 
handling  even  with  sterile  gloved  hands. 


Fig.   43. — Spinal  graft  for  Pott's  disease  in  place  and  kangaroo-tendon  sutures 

being  inserted. 

Fixation  of  the  graft  in  position. — If  the  graft  is  a  straight 
one,  it  is  held  in  place  by  first  passing  a  strong  kangaroo-tendon 
suture  through  one-half  of  the  split  supraspinous  ligament  at 
one  side  of  the  gutter;  then  the  suture  is  passed  up  over  the 
graft  at  its  middle  portion  and  through  the  other  split  half  of 
the  supraspinous  ligament  opposite.  This  suture  is  drawn 
taut  and  tied,  thus  approximating  the  two  halves  of  the  split 
supraspinous  ligament  over  the  graft  at  its  central  portion. 
The  ends  are  next  secured  in  like  manner,  always  aiming  to 
pass  the  suture  deeply  so  as  to  get  a  firm  hold  upon  the  ligament 
and  close  to  the  spinous  processes,  either  above  or  just  below 


8G  BONE-GRAFT   SURGERY 

them.     This  insures  a  firmer  contact  of  the  graft  to  the  separated 
halves  of  the  spUt  processes. 

In  certain  instances  it  is  advisable  to  place  the  suture  either 
in  the  supraspinous  ligament  midway  between  the  spinous 
processes  or  at  a  varying  distance  to  the  side  of  these  processes, 
in  order  that  the  ligament  may  yield  and  the  graft  be  completely 
covered.     In  the  lumbar  region,  especially  in  adults,  the  supra- 


FiG.  44. — Pott's  disease  of  third  and  fourth  cervical  vertebrae  (at  D)  with  almost 
complete  paralysis  of  the  right  arm.  The  graft  AB  was  inserted  with  immediate  relief 
of  all  symptoms,  including  the  paralysis  of  the  arm,  in  10  days  time.  C  indicates  small 
grafts.     For  anterior-posterior  view,  see  Fig.  45. 

spinous  ligament  may  be  so  dense  and  tense  that  it  is  difficult 
on  account  of  the  required  thickness  of  the  graft  to  cover  it 
satisfactorily  unless  the  vertebral  aponeurosis  is  incised  on  either 
side  just  external  to  the  line  of  sutures.  This  allows  a  separation 
of  the  ligament  sufficient  to  cover  the  graft. 

Before  the  two  ends  of  the  graft  are  secured  in  position, 
it  should  be  made  certain  that  the  graft  reaches  far  enough  be- 
low the  diseased  vertebrae  to  include  two  healthy  spines;  also 


pott's  disease  and  other  spinal  lesions 


87 


the  same  should  be  made  certain  above  the  diseased  area. 
Emphasis  is  laid  upon  having  the  graft  reach  low  enough  be- 
cause on  account  of  the  natural  obliquity  of  the  spinous  proc- 
esses in  certain  segments  of  the  vertebral  column,  as  in  the 
thoracic  region,  the  fact  that  the  tips  are  well  below  their  corre- 
sponding bodies  may  be  somewhat  misleading  and  the  applied 
graft  may  be  insufficient  in  not  including  the  healthy  vertebral 


Fig.  45. — Antero-posterior  view  of  same  case  as  Fig.  44. 


spines  below.  Also,  at  this  point  in  the  fixation  of  the  ends  of 
the  graft  into  position,  the  sharp  posterior  corners  are  removed 
by  Rongeur  forceps,  and  these  bone  chips  are  placed  about 
and  under  the  graft  ends  before  tying  the  graft  end  sutures. 
The  graft  ends  should  be  sure  to  contact  with  spinous  processes. 
The  small  fragments  of  bone  so  placed  furnish  added  foci  for 
bone  proliferation,  so  as  still  more  securely  to  amalgamate  the 
graft  ends  to  the  contacted  spinous  processes,  it  being  borne  in 


88 


BONE-GRAFT   SURGERY 


mind,  as  Alacewcn  has  pointed  out,  that  the  bone  graft  varies 
in  its  osteogenesis  in  inverse  ratio  to  its  volume.  In  other  words, 
the  smaller  the  graft  the  greater  its  comparative  surface  and  the 
more  active  its  bone-growing  ability.  It  has  been  further  dem- 
onstrated that  small  grafts,  because  of  their  size,  obtain  their 


Fig.   46. — Position  of  patient  and  adjustment  of  head-rest  for  insertion  of  spinal  graft 
for  Pott's  disease  of  cervical  region. 


nourishment   more   readily   from   their   surrounding   serum   or 
blood,  and  a  periosteal  covering  is  not  essential. 

Kangaroo-tendon  sutures  at  intervals  of  half  an  inch  are  now 
passed  in  similar  manner  as  the  sutures  mentioned  above,  until 
the  entire  length  of  the  graft  is  closed  in  and  firmly  secured  in 
position. 


pott's  disease  and  other  spinal  lesions  89 

If  the  graft  is  a  curved  one,  cut  from  the  surface  of  the  tibia 
according  to  the  pattern  previously  determined,  the  graft  when 
placed  in  its  bed  must  necessarily,  from  its  curved  shape,  in 
order  to  fit  the  deformity,  be  placed  edgewise,  so  that  its  perios- 
teal surface  lies  to  one  side  and  its  marrow  surface  to  the  other. 


Fig.  47. — To  demonstrate  a  bone  graft  inserted  for  Pott's  disease  with  a  lateral 
deviation  of  the  spine.  The  spinous  processes  are  split  in  as  straight  line  as  possible  and 
then  the  graft  is  moulded  to  meet  the  condition. 

The  graft  is  so  placed  that  the  marrow  or  saw-cut  surface  shall 
contact  with  the  side  of  the  gutter  formed  by  the  unfractured 
halves  of  the  spinous  processes,  and  this  periosteal  surface,  conse- 
quently, contact  with  the  opposite  side  of  the  gutter  contain- 
ing the  fractured  halves  of  the  spines.     The  endosteal  surface 


90  BONE-GHAFT   SURGERY 

of  the  graft  with  its  attached  marrow  sul:>stance  seems  to  be 
more  active  in  its  bone  proUferative  power  than  the  periosteal 
surface.  The  curved  graft  is  secured  in  position  in  the  same 
manner  as  the  straight  graft. 

If  the  graft  to  be  used  is  a  straight  graft  with  transverse  saw- 
cuts  made  two-thirds  to  three-quarters  through  its  thickness, 
cutting  on  its  marrow-surface,  the  graft  had  best  be  taken  from 
the  lower  two-thirds  to  three-quarters  of  the  antero-internal 
surface  of  the  tibia,  where  the  cortex  is  thick,  and  to  include 
the  crest  or  not  as  the  operator  chooses.  If  the  graft  is  removed 
from  the  antero-internal  surface,  not  including  the  crest,  the 
twin  saw  hastens  its  removal  and  insures  its  uniform  width 
throughout.  If  the  crest  is  to  be  included,  cuts  at  right  angles 
to  each  other  on  each  side  of  the  crest  are  necessary.  The  graft 
in  this  case  includes  two  periosteal  surfaces,  and  therefore  is 
more  active  osteogenetically  and  is  mechanically  stronger. 
Again,  it  is  emphasized  that  every  graft  should  include  all  bone 
elements,  namely,  periosteum,  compact  bone,  endosteum,  and 
marrow  substance.  This  is  the  author's  bent-in  graft,  and  as 
the  transverse  saw-cuts  naturally  weaken  the  graft,  when  possible 
the  moulded  graft,  as  previously  described,  should  always  be 
used. 

In  making  the  transverse  saw-cuts  to  allow  the  graft  to  bend, 
as  a  carpenter  cuts  a  board  to  cause  it  to  bend  about  a  curved 
surface,  the  graft  is  held  securely  by  the  operator  with  two  strong 
clamps,  one  at  either  end.  With  the  motor  held  by  an  assistant 
firmly  against  the  instrument  table  and  the  saw  overhanging 
the  edge  (Fig.  48),  the  current  under  control  of  the  foot-switch 
is  turned  on  by  the  operator,  who  is  in  a  position  to  regulate  the 
spacing  and  depth  of  the  cuts  along  the  marrow  surface  of  the 
graft  as  he  presses  the  graft  against  the  rapidly  revolving  saw 
from  below.  By  holding  the  graft  in  this  way,  he  is  able  to  test 
its  flexibility  (Fig.  48C)  as  he  proceeds  with  its  cutting,  and  can 
judge  very  accurately  when  he  has  produced  the  desired  flexi- 
bility in  the  graft  to  enable  it  to  conform  to  the  bed  and  span  the 
deformity,  without  actually  having  repeatedly  to  place  the  graft 


pott's  disease  and  other  spinal  lesions 


91 


in  the  bed  to  determine  its  adaptation  to  the  kyphosis.  The 
uniform  depth  of  the  saw-cuts  is  regulated  by  adjusting  the 
proper  guard  to  the  saw,  in  accordance  with  the  thickness  of 
each  graft.     This  expedites  matters,  as  the  surgeon  has  no  fear 


Fig.  48. — A,  the  manner  of  holding  the  graft  while  making  the  transverse  saw-cuts 
to  increase  its  flexibility. 

B,  transverse  saw-cuts  at  equal  intervals  and  three-quarters  through  the  diameter  of 
the  graft  on  its  marrow  surface. 

C,  testing  for  the  desired  amount  of  curve  in  the  graft  obtained  by  making  the  trans- 
verse saw-cuts  before  applying  it  to  the  kyphosis  of  the  spine. 

of  entirely  severing  the  graft  and  the  saw  cuts  to  the  same 
depth  at  each  point.  The  author's  automatic  spray  attachment 
provides  a  constant  spray   of   saline   solution   upon   the   saw, 


92 


BONE-GRAFT   SURGERY 


proventing  any  possibility  of  over-heating.     This  is  an  important 
l)oint.  as  otherwise  osteogenetic  eells  may  be  destroyed. 

hi  the  a))j)lication  of  the  Ijciit-in  <:,iatt,  tlie  medullary  .sur- 
face (bearing  the  transverse  saw-cuts;  natur;ill>-  lies  next  to  the 
gutter  bed,  with  the  periosteal  surface  posteriorly.  The  edges  of 
this  graft  contact  with  the  cut  surfaces  of  the  gutter  sides  and 
the  split  spines.  The  same  method  is  adopted  in  the  application 
of  the  sutures  as  is  used  in  securing  the  other  shaped  grafts,  with 


Fig.  49. — Method  of  socuririK  the  bent  in  bone  graft  to  adapt  it  to  the  curve  of  the 
kyphosis.  (I)  First  fixation  suture.  (2;  Ser-ond  fixation  suture.  The  arrow  indicates 
the  direction  which  the  graft  is  to  be  bent  to  fit  over  the  kyphosis. 


the  exception  that  the  bent-in  graft  is  completely  sutured  into 
position  at  one  end  while  the  other  end  projects  ready  to  be 
bent  in,  and  the  interrupted  sutures  are  then  inserted  consecu- 
tively (see  Fig.  49j  until  the  projecting  ftid  of  llic  graft  is 
reached  and  the  })]afiiig  of  llic  imlccldiug  sutures  is  completed. 
If  the  bent-ill  graft  is  lield  by  one  imbedding  suture  applied 
at  each  end,  holding  it  bent  into  position  while  the  other  sutures 
are  added,  the  graft  is  in  danger  of  fracturing  through  one  of 
its  transverse  saw-cuts.  In  any  case,  whether  this  fracture  of 
the  graft  occurs  or  not,  it  is  well  to  reinforce  this  graft  by  placing 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


93 


along  each  of  its  sides,  at  the  niaxinuun  point  of  eiir\'atiire.  thin 
strips  of  cortical  bone  cut  with  the  motor  saw  from  the  tibia 
where  the  graft  was  obtaineil. 

The  skin  womul  is  closed  in  the  usual  way  and  sterile 
dressings  are  applied.  Thick  pads  of  gauze  and  cotton,  varying 
in  thickness  according  to  the  degree  of  the  kyphosis,  are  placed 
on  each  side  of  the  implanted  graft.  This  is  important  in  order 
to  prevent  pressure  sores  on  the  apex  of  tlie  grafted  kyphosis. 
The  dressings  and  pads  art>  then  >eciu'ed  in  ]ihu-e  I'y  liroad  -trips 


Fig.   50. — The  l>ent-in  graft  in  position,  with  the  intorrnpted  kangaroo-tondon  sntures 
being  phieed  to  seeure  it  and  enehise  it  Innieath  the  snpraspinons  ligament. 

of  zinc  oxide  adhesive  plaster.  It  is  not  safe,  even  with  this 
dressing,  to  allow  i^jatitrnts  with  prominent  kyjihosis  to  lie  upon 
the  back,  but  they  nui-t  \h'  I'estrained  upon  \\\c  >\({c  or  obHquely 
on  the  back  during  the  post-operative  riHaimlnMit  period. 

Tlie  technique  just  deseribed  is  a]ipHed  to  the  bone-graft 
implantation  into  all  st^gimaits  of  the  spini\  The  anatomical 
variations  of  tlu^  spinous  proi'osses  of  the  different  segnuaits  nuist 
be  borne  in  mind,  as  wtdl  as  the  increased  strain  aiul  le^■erage 
action  of  the  diffcM'ent  si^gmtMits.  For  instaiUH\  in  tlu^  C(M-\ical 
or  upper  thoracic  region,  being  at  the  up]HM'  end  or  portion  oi  the 
spine,  the  strain  ]ilac(Hl  upon  the  graft  is  uuich  less  than  lower 
down,  from  the  mid-thorai'ic  roo-jon  to  tin'  saiTiim.  Tlu^  strain 
and  Kwerage  at'tion  oi  the  coliunn.  as  a  whole,  increast^  materialh' 


94 


BONE-GRAFT   SURGERY 


Fig.  51. — Lateral  rontgenogram  of  a  spine  of  a  man  22  years  old,  which  is 
illustrative  of  the  extreme  degree  to  which  an  adult  tibial  bone  graft  can  be  bent.  C 
indicates  the  saw  cuts  in  the  marrow  side  of  the  graft.  This  case  had  been  under  con- 
servative treatment  17  years  as  a  private  ease  by  two  very  competent  orthopsedic  sur- 
geons; nevertheless,  a  relapse  with  paraplegia  occurred  after  that  period  of  treatment. 
The  result  after  the  insertion  of  the  bone  graft  was  immediate  and  excellent. 


pott's  disease  and  other  spinal  lesions 


95 


toward  the  sacrum.  In  the  act  of  flexion,  side-benchng,  or 
rotation,  the  farther  away  from  the  general  centre  of  the  long 
axis  of  the  total  lever  a  graft  is  implanted,  the  less  is  the  strain 
placed  upon  it;  so  that  a  graft  implanted  into  the  lumbar  re- 


FiG.  52. — Graft  AB  inserted  for  acute  Pott's  disease  with  discharging  sinuses  in  both 
iliac  fossae.     Symptoms  were  relieved  and  sinuses  healed  in  10  weeks  time. 

gion  will  have  a  greater  amount  of  strain  to  resist  than  one  at 
any  segment  above.  In  this  region,  the  general  leverage  that 
will  have  direct  bearing  upon  the  graft  includes  not  only  the 
weight  and   force   applied   through   the   entire   length   of    the 


96  BONE-GRAFT   SURGERY 

spinal  column  above  the  inii)lanted  graft,  but  also  includes 
the  force  of  the  leverage  action  of  that  portion  of  the  trunk 
and  lower  limbs  whicli  extends  below  the  graft.  The  grafted 
area  is  here  considei-ed  the  fulcrum,  consequently  the  graft 
should  be  relatively  stronger.  This  added  strength  is  supplied 
by  inserting  a  broader  graft,  and  as  in  the  lumbar  region  we 


Fig.  53. — Acute  Pott's  disease  of  the  lower  thoracic  region  with  large  psoas  abscess, 
4  years  after  the  insertion  of  a  tibial  graft.  The  abscess  immediately  disappeared  and 
the  patient  has  not  lost  a  day's  work  on  account  of  his  back  since  7  weeks  after  the 
operation. 

seldom  find  a  kyphosis  of  very  great  angulation,  a  straight 
graft  with  no  transverse  saw-cuts  can  usually  be  employed. 

The  graft  is  applied  readily  between  the  bifid  portions  of 
cervical  spines,  as  well  as  to  the  corresponding  projections  on 
the  posterior  surface  of  the  sacrum  in  low  lumbar  Pott's  disease. 

The  Immediate  Post-operative  Treatment. — The  immediate 
post-operative  care  of  these  cases  consists  in  recumbency  upon 
the  back  on  a  fracture  bed  for  5  weeks  in  adult  cases  and   6 


pott's  disease  and  other  spinal  lesions  97 

weeks  for  children,  with  no  more  restraint  than  that  afforded 
by  pinning  a  towel  about  the  thorax  to  which  are  attached  four 
strips  of  a  broad  muslin  bandage.  Two  strips  are  pinned  to 
the  upper  side  of  the  encircling  towel  in  front,  to  be  secured  to 
each  side  of  the  mattress  of  the  bed  above  the  shoulders.     The 


^A 


B 


Fig.   54. — This  rontgenogram  demonstrates  the  large  amount  of  proHferation  a  spinal 
graft   (AB)  will  undergo  when  the  mechanics  of  its  environment  demand  it. 

remaining  two  strips  of  bandage  are  fastened  to  the  encircling  towel 
near  its  lower  edge  and  to  the  two  sides  of  the  mattress  at  the  foot 
end  of  the  bed  (Fig.  56).  These  restraining  bandage  strips 
are  so  placed  to  prevent  the  patient  from  attempting  to  sit  up 
or  roll  from  side  to  side,  and  are  usually  necessary  only  with 


98 


BONE-GRAFT    SURGERY 


children.     Adult  patients,   as   a   rule,   lie   recumbent   without 
restraint. 

Where  the  spine  presents  a  marked  kyphosis,  it  is  neces- 
sary to  apply  thick  pads  of  soft  material  on  each  side  of  the 


B 


-H 


Fig.  55. — Acute  Pott's  disease  of  fourth  and  fifth  lumbar  vertebrae  in  a  laborer  of 
22  years.  Two  abscesses  size  of  cocoanuts  in  iliac  fossae.  At  Roosevelt  Hospital  (Dr. 
Chas.  H.  Peck's  Service),  Feb.  12,  1913,  a  tibial  graft  was  inserted  into  the  spinous 
processes  of  the  third,  fourth  and  fifth  lumbar  vertebrae  and  sacrum.  The  patient 
went  to  work  as  a  laborer  in  a  brickyard  2J^  months  after  operation.  In  September, 
61.^  months  after  the  operation,  he  obtained  a  position  as  fireman  and  has  continued  to 
shovel  coal  ever  since.  In  Feb.,  1914,  just  1  year  after  the  operation,  he  reported  at  the 
O.  P.  D.  for  examination,  although  he  had  no  complaints  to  make.  No  evidence  of 
his  former  psoas  abscesses  could  be  palpated,  although  they  had  never  been  aspirated 
and  no  spinal  support  had  been  worn. 

spine  before  placing  the  patient  on  his  back,  or  when  there  is  an 
excessive  deformity  it  is  best  to  secure  the  patient  in  bed  lying 
upon  his  side,  to  obviate  undue  pressure  on  the  grafted  area, 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


99 


in  this  way  preventing  necrosis  of  the  skin  flap.  For  a  similar 
reason,  it  is  unwise  to  employ  the  gas-pipe  frame  with  its  rigid 
canvas  covering,  or  a  plaster-of-Paris  jacket,  immediately  fol- 
lowing the  operation.  The  slight  amount  of  motion  produced 
by  respiration  is  not  detrimental  to  the  adhesion  of  the  graft, 
but  rather  is  considered  to  stimulate  proliferation  of  callus  be- 
tween the  contacting  cut  surfaces  of  bone  and  thus  hasten  the 
fixation  of  the  graft. 


Fig.   56. — Method  of  fixation  in  Ijcd  after  the  bone-graft  implant  for  Pott's  disease  has 

been  applied. 

The  General  Post-operative  Treatment  and  Convalescence. 

— It  should  be  observed  that  while  the  implantation  of  this  bone 
graft  for  the  purpose  of  ankylosing  the  affected  vertebrae  ac- 
complishes the  long-sought-for  immobilization  of  these  diseased 
joints,  it  does  not  directly  remove  the  disease  itself,  which  is 
an  impossibility.  However,  as  ankylosis  of  other  tuberculous 
joints  has  proved  so  satisfactory  in  arresting  the  disease  with- 


100 


BONE-GKAFT   SURGERY 


out  requiring  the  removal  of  all  the  infected  bone  (as  evidenced 
in  cases  of  knee-  and  hip-joint  disease,  see  Chapters  V  and  VI), 
so,  in  the  case  of  tuberculous  infection  of  the  vertebral  joints, 
ankylosis  acts  with  even  greater  advantage  in  that  by  the  bone 


\ 


Fig.  57. — Lateral  iunt;j:i-ii'j;;iLiiii  i_m  Ulii<U:it<.'  tln'  bone  graft  in  place  after  18  months 
and  the  efficacy  with  which  it  is  holding  the  spine,  although  the  vertebral  bodies  at  CD 
are  entirely  disintegrated  and  absorbed.  This  destruction  occurred  before  the  graft 
was  inserted. 

graft  implanted  in  the  spinous  processes  the  vertebrae  are  not 
only  ankylosed,  but  their  diseased  bodies  can  be  separated,  thus 
removing  active  causative  elements  in  the  extension  of  the 
disease.    Although,  as  a  rule,  the  patient  is  immediately  relieved 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


101 


from  symptoms  and  evidence  of  active  disease,  he  should  have 
the  general  careful  regime  of  bodily  rest,  wholesome  feeding, 
sunlight  and  fresh  air  that  has  been  found  of  so  great  impor- 
tance in  these  cases  heretofore. 

It  is  always  advisable  that  in  these  cases  6  months  or  more 
of  post-operative  convalescence  shall  have  passed  before  the 
patients  resume  active  or  heavy  work.  However,  in  a  number 
of  instances  where  the  author  has  applied  the  bone  graft  for 


Fig.  5S. — A  group  of  17  children  at  the  Blythedale  Home,  Hawtliurni',  X.  Y.,  all  of 
whom  have  had  the  bone  graft  inserted  for  Pott's  disease.  The  convalescence  of  all  has 
been  most  satisfactory  and  without  plaster  jackets. 

One  of  this  number  had  been  operated  at  another  clinic  and  came  to  the  Home 
wearing  a  plaster  jacket  about  10  weeks  after  the  bone  graft  had  been  implanted.  It 
was  noticed  that  in  spite  of  the  jacket  the  child  refused  to  play,  rested  his  chin  in 
his  hand  and  had  night  cries.  A  rontgenogram  was  taken  and  it  showed  that  the  graft 
only  included  one-half  of  the  vertebrae  involved.  A  second  operation  was  done  and  the 
graft  lengthened  to  include  sufficient  vertebrae,  and  from  that  time  his  spinal  symptoms 
have  entirely  disappeared. 


Pott's  disease  in  adults,  they  have  returned  to  work  in  6  to  8 
weeks  after  the  operation,  and  without  external  support.  These 
were  patients  who  had  been  compelled  to  cease  work  on  account 
of  the  disease  but  who,  because  of  necessity,  as  soon  as  pain  and 
weakness  were  relieved  felt  obliged  to  return  to  work  against 
advice. 

Children  should  have  at  least  a  year  of  more  or  less  restraint 
from  general  activity,  with  daily  rest  periods  and  outdoor  life. 


102  BONE-GRAFT   SURGERY 

It  proves  particularly  beneficial  to  these  cases,  following  the  5 
to  6  weeks'  post-operative  confinement  in  bed,  if  they  can  be  re- 
moved from  the  city  to  more  healthy  surroundings  in  the 
country.  In  other  words,  they  should  be  managed  in  a  similar 
way  to  cases  suffering  from  lung  or  glandular  tuberculosis. 
This  can  be  carried  out  in  every  detail,  because  the  mechanical 
spinal  requirements  have  been  met  by  the  implanted  bone  graft. 
In  the  Blythedale  Home  for  Tuberculous  Crippled  Children  the 
author  has  a  very  valuable  example  of  these  advantages,  as 
evidenced  in  such  of  these  cases  as  could  take  the  opportunity 
this  Home  offered,  compared  with  those  who  were  not  so 
fortunate  and  remained  in  the  city. 

External  Support  to  the  Spine  during  Convalescence. — ^As 
a  general  rule,  the  author  has  followed  the  practice  of  applying 
no  external  fixation  to  the  spine  after  his  operation.  There  are 
certain  cases  and  exceptions,  however,  where  for  definite  reasons 
it  has  been  deemed  advisable  to  have  the  patient  wear  a  spinal 
brace  or  a  plaster-of-Paris  jacket  for  varying  lengths  of  time 
after  the  5  or  6  weeks  of  immediate  post-operative  fixation  in 
bed. 

For  instance,  when  it  is  necessary  for  the  patient  to  leave  the 
hospital  before  the  prescribed  period  of  5  to  6  weeks  in  bed  has 
elapsed;  or  in  cases  where  a  marked  kyphosis  in  the  thoracic 
region  has  developed  before  the  operation,  necessitating  a  tem- 
porary weakening  of  the  graft  by  transverse  saw-cuts  in  order 
to  bend  it  into  place.  In  addition,  such  a  graft  is  subject  to 
strain  varying  according  to  the  severity  of  the  kyphosis.  In 
these  cases  a  plaster-of-Paris  jacket  is  advisable  for  a  few  months, 
or  a  longer  period  of  recumbency  in  bed. 

SUMMARY 

Remarks  on  the  Employment  of  Bone-graft  Fixation  of  the  Vertebrae  in  Pott's 
Disease,  and  Its  Advantages 

Following  the  bone  graft,  the  full  natural  leverage  action  of 
each  vertebra  is  not  lost  but  is  changed  from  a  crushing  together 
of  the  bodies  anteriorly  (due  to  respiratory  motion,  contraction 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


103 


of  abdominal  muscles,  and  general  attempt  on  the  part  of  nature 
to  immobilize  the  diseased  vertebrae)  to  a  pulling  of  the  anky- 
losed  spinous  processes  on  the  ankylosing  graft  posteriorly. 
The  change  from  the  crushing  effect  taking  place  in  the  bodies 
by  the  approximation  of  the  anterior  arms  of  the  levers  to  a 
traction  effect  through  the  long  axis  of 
the  graft  implanted  in  the  ends  of  the 
posterior  arms  of  the  levers,  preventing 
separation  of  the  spinous  processes,  is  ob- 
vious. The  fulcra  of  these  levers  remain 
constant.  In  comparatively  early  cases 
of  sharply  angular  antero-posterior  de- 
formity of  the  spine,  further  progress  of 
the  kyphosis  can  be  prevented  and  actual 


Fig.  59. 


Fig.  60. 


Figs.  59  and  60. — A  very  acute  case  of  tuberculosis  of  lumbar  spine,  3  months 
after  bone  graft  was  inserted.  Child  has  remained  well  2  years  after  operation.  The 
excellent  spinal  function  is  shown. 

correction  maintained  by  this  bone-graft  implantation.  Besides 
accomplishing  this,  the  accurate  immobilization  of  the  involved 
segment  of  the  spinal  column  is  secured  without  interference 
with  body  activity  or  respiratory  function,  or  resorting  to 
protracted  recumbency,  fixation  on  a  gas-pipe  frame,  plaster-of- 
Paris  jacket  or  brace. 


104  BONE-GKAFT   SUKGERY 

Indications  for  Operative  Treatment. — Fixation  by  the 
bone  graft  is  indicated  in  all  cases  and  at  all  ages  where  pain 
or  muscle-spasm  demands  it,  and  the  earlier  the  operation  the 
more  favorable  the  prognosis.  It  is  indicated  for  the  prevention 
and  correction  of  increasing  deformity,  and  is  even  more  ur- 
gently demanded  in  the  presence  of  complicating  conditions, 
such  as  psoas  spasm,  cold  abscesses,  or  paraplegia. 

The  only  special  centra-indication  is  the  inability  to  secure 
a  clean  field  of  operation.  This,  however,  is  rare,  as  cold  ab- 
scesses seldom  point  in  or  invade  the  region  of  the  spinous  proc- 
esses. Uninfected  cold  abscesses  between  the  spinous  processes 
have  not  interfered  with  primary  union  of  the  graft,  when 
encountered  unexpectedly  in  implanting  the  graft,  and  cases 
can  be  cited  where  bone  grafts  have  spanned  through  these 
cold  abscesses  with  no  detriment  to  the  graft  or  delay  in  its 
bony  union. 

Prognosis  Following  the  Bone -graft  Operation. — The  prog- 
nosis in  all  operated  cases  is  most  favorable,  as  to  relief  of  all 
symptoms  and  decrease  of  the  deformity.  Correction  of  de- 
formity is  most  favorable  in  cases  of  children  operated  on  early; 
and  in  cases  of  longer  duration  where  the  kyphosis  is  sharply 
angular,  or  presents  a  considerable  amount  of  motion,  a  certain 
amount  of  correction  is  possible. 

In  250  cases  operated  upon  by  the  author,  a  surprising 
amount  of  respiratory  mobility  was  noted  in  the  centre  of  the 
kj^phosis  in  all  early  cases,  as  well  as  in  a  considerable  percentage 
of  cases  of  even  4  to  6  years'  duration.  These  observations 
were  made  after  the  spinous  processes  were  exposed  and  while 
the  patient  was  lying  prone  on  a  firm  operating  table,  breathing 
quietly  under  an  anaesthetic.  Under  these  conditions,  slight 
motion  only  could  be  detected  between  the  healthy  vertebrae 
above  or  below  the  kyphosis.  Undoubtedly  the  reason  for  this 
increased  motion  is  the  loss  of  support  due  to  the  destruction 
and  absorption  of  the  diseased  vertebral  bodies,  leaving  only  the 
lateral  masses  with  their  articular  facets  and  the  spinous  proc- 
esses to  support  the  column. 


pott's  disease  and  other  spinal  lesions  105 

The  prognosis  is  much  influenced  by  the  patient's  post- 
operative environment  and  daily  regime  of  life.  This  is  of  as 
great  importance  as  in  the  case  of  tubercular  involvement  of 
other  organs.  Rest,  forced  feeding,  fresh  air,  and  exposure  to 
sunlight  are  important  elements  of  treatment. 

With  the  object  of  ascertaining  the  results  obtained  by  other 
surgeons  with  the  bone-graft  treatment  for  Pott's  disease,  a  large 
number  of  printed  question  blanks  were  sent  out  to  everj''  surgeon 
who,  it  was  known,  had  done  this  operation,  in  this  country 
and  foreign  countries. 

From  these  blanks  and  the  author's  personal  cases  the  fol- 
lowing statistics  of  532  cases  were  tabulated : 

The  ages  of  the  patients  vary  from  20  months  to  65  years. 
The  duration  of  the  disease  (and  this  in  many  cases  was 
sj'Uonymous  with  duration  of  previous  conservative  treatment) 
was:  under  1  year  58  cases;  over  1  year  71  cases;  over  2 
years  62;  over  3  j^ears  71  cases;  over  4  years  56  cases;  over  5 
years  36  cases;  over  6  years  33  cases;  over  7  years  21  cases;  over 
8  years  16  cases;  over  9  years  13  cases;  over  10  years  10  cases; 
over  11  years  8  cases;  over  12  years  8  cases;  over  15  A^ears  5 
cases;  over  19  years  3  cases;  over  21  years  5  cases;  over  26  years 
2  cases. 

Location  of  Disease. — Cervical  spine  6  cases;  Cervico-dorsal 
region  42  cases;  dorsal  region,  168  cases;  Dorso-lumbar  78  cases; 
lumbar  122  cases;  lumbo-sacral  34  cases. 

Thirty-one  surgeons  reported  a  total  of  292  results,  in  222 
of  which  the  disese  was  pronounced  arrested.  In  59  the  condi- 
tion was  improved.  Twelve  cases  died,  4  of  which  were  reported 
as  from  shock.  The  remaining  8  cases  died  4  months  or  longer 
after  operation  from  either  complications  or  intercurrent 
diseases.  In  5  of  these  cases  the  spinal  condition  was  entirely 
controlled.  In  3  of  4  cases  dying  from  shock,  the  chisel  and 
mallet  were  used  to  obtain  the  graft. 

Fourteen  of  the  31  surgeons  reported  100  per  cent,  of  cases 
of  good  results  (disease  arrested).     There  were  8  surgeons  who 


106  BONZ-GRAFT   SUKGERT 

reported  that  they  did  not  use  plaster  jackets  or  spinal  supports 
beyond  the  period  of  immediate  p)ost-operative  recumbency. 
Seven  of  these  men  obtained  100  per  cent,  of  good  results  and 
one  secured  SS  per  cent,  of  good  results. 

Of  the  author's  personal  cases  only  those  that  have  been 
operated  1  year  or  longer  are  included  in  this  report.  Of  these 
there  are  19S.  In  1S4  the  disease  was  arrested.  In  two  there 
was  improvement. 

Up  to  the  present  time  12  have  died:  6  of  these  eases  were 
entirely  relieved  of  their  Pott's  disease  and  died  from  some  inter- 
current disease.  One,  a  child  of  6  years,  in  poor  general  condition, 
after  5  years  of  conservative  treatment  died  the  next  day  after 
the  operation,  cause  imknown;  the  graft  in  this  case  was 
removed  with  chisel  and  mallet:  one  case  in  4  days  from  ace- 
tonuria:  one  from  status  lymphaticus:  one  from  middle-ear 
disease  compUcated  by  a  suppurative  meningitis,  two  years 
after  the  spinal  operation.  The  autopsy  showed  a  complete 
cure  of  the  tuberculous  spine.  One  died  about  1  week  after 
operation  from  pneumonia.  The  causes  of  the  death  of  others 
have  been  amyloid  degeneration  of  the  viscera,  tuberculosis  of 
the  lung,  and  acute  abdominal  condition. 

There  have  been  only  3  cases,  of  the  532,  die  of  tuberculous 
meningitis,  and  there  has  been  no  serious  trouble  with  the  tibia 
from  which  the  graft  was  removed  in  any  case. 

Of  the  total  number  (532)  in  449  the  disease  was  arrested, 
in  59  the  condition  was  improved,  in  9  the  condition  was  un- 
improved. There  were  9  deaths  soon  after  the  operation,  and 
6  deaths  occurred  long  after  the  operation  and  were  relieved  of 
their  spinal  symptoms.  The  percentage  of  results  of  this  large 
number  of  cases  is  most  gratifying,  especially,  when -it  is  realized 
that  most  of  these  cases  were  operated  and  treated  during  a 
period  when  the  technique  of  procedure  was  being  developed. 

With  the  present  motor  tools  and  the  perfected  technique  it 
is  beheved  that  a  fatality  from  shock  should  practically  never 
happen. 


pott's  disease  axd  other  spixal  lesions  107 

experimext-\l  application  of  the  method  to  the  spixes  of 

13  DOGS,  VERIFYI^"G  THE  WORK  DOXE  ON  THE 

Hv :•:.-.:.'  subject 

The  special  object  of  the  animal  experimentation  about  to  be 
described  was  to  afford  means  for  studying  both,  macroscopically 
and  microscopically,  a  bone  graft  when  implanted  in  a  dog  by 
the  same  technique  as  that  employed  by  the  author  in  the  human 
subject  for  the  treatment  of  Pott's  disease  of  the  spine. 

REPORT   OF  EXPERIMENTS 

Experiment  1. — December  10.  1911.  Dog.  mongrel,  male; 
approximate  weight,  30  lb.  Ether  anaesthesia.  Anaesthetist, 
]Mr.  Cassellius.  Fields  of  operation:  thoracic  region  of  back 
and  left  foreleg,  prepared  by  shaving  and  scrubbing  with  tinc- 
ture of  green  soap  and  water,  followed  by  corrosive  sublimate, 
1:1.000.  and  70  per  cent,  alcohol.  The  spinous  processes  of 
three  of  the  mid-dorsal  vertebrse  were  approached  by  an  incision 
through  the  skin  and  areolar  tissue  directly  over  their  tips. 
The  supraspinous  and  interspinous  ligaments  were  spHt  with  a 
scalpel  to  a  depth  of  two-thirds  of  an  inch  between  the  spinous 
processes,  without  disturbing  the  attachments  of  the  hgaments 
to  the  spinous  processes.  Each  of  the  three  spinous  processes 
was  spUt  longitudinally  with  a  chisel  and  mallet  into  halves, 
for  a  depth  of  about  two-thirds  of  an  inch,  care  being  taken 
that  the  right  halves  of  the  spinous  processes  were  not  broken. 
A  separation  of  the  tips  of  the  halves  of  these  spinous  proc- 
esses produced  a  wedge-shaped  cavity,  into  which  the  ulnar 
transplant  was  later  inserted.  A  hot  saline  compress  was 
placed  in  the  wound  untU  the  bone  insert  was  obtained. 
This  was  for  the  purpose  of  securing  as  perfect  haemostasis  as 
possible  for  the  bone-graft  bed.  Half  the  diameter  of  the 
shaft  of  the  dog's  right  ulna  was  then  removed  with  chisel 
and  bone  forceps.  The  graft  consisted  of  periosteum,  compact 
bone,  endosteum,  and  marrow  substance.  It  was  inserted 
between  the  halves  of  the  interspinous  Ugaments  and  spinous 
processes,   and  held   in    place    with    interrupted    sutures    of 


108  EONE-GRAFT    SURGERY 

linen,  which  were  passed  through  the  supraspinous  Hgaments 
and  the  posterior  edge  of  the  halves  of  the  interspinous 
ligaments  near  the  tip  of  each  spinous  process.  These  liga- 
ments were  thus  drawn  over  the  graft  posteriorly.  The  pro- 
cedure was  precisely  that  which  has  been  applied  to  human 
subjects. 


Fig.  61. — Photograph  of  three  vertebrae  of  a  dog  bridged  together  by  a  strong  bone 
graft  AB.  This  specimen  was  obtained  at  necropsy  6  months  after  the  graft  was 
inserted. 


December  13,  the  wound  was  septic.  December  20,  much 
pus  was  discharging  from  the  wound.  The  sinus  slowly  de- 
creased in  size  during  the  next  few  weeks. 

Necropsy. — May  28,  1912.  The  wound  had  healed,  with  the 
exception  of  a  small  sinus.  A  sliver  of  nearly  one- third  the 
diameter  of  the  graft  anteriorly  and  tapering  to  a  pointed  end 


pott's  disease  and  other  spinal  lesions  109 

posteriorly  had  sequestrated  from  the  rest  of  the  graft,  which 
had  become  firmly  united  to  the  spinous  processes.  The  whole 
posterior  diameter  had  lived  and  become  firmly  grown  into  the 
spinous  processes.     Although  sepsis  had  occurred  and  no  at- 


FiG.  62. — View  of  a  dog's  vertebra  (Experiment  1),  into  the  spinous  process  of 
which  a  portion  of  his  ulna  had  been  ingrafted  6  months  before;  A,  B  and  C indicate  the 
outlines  of  the  graft,  which  has  become  firmly  grown  into  the  split  spinous  process. 
Fig.  66  is  from  a  photomicrograph  of  a  section  of  graft  at  this  point.  E  is  articular 
facet. 

tempt  had  been  made  to  immobilize  the  dog's  spine,  the  result 
was  a  bridge  of  bone  uniting  three  vertebrae.  X-ray  examina- 
tions of  the  gross  specimen  and  a  microscopic  study  of  decalci- 
fied and  non-decalcified  sections  failed  to  show  degeneration  of 


110  BONE-GRAFT   SURGERY 

that  part  of  the  graft  which  had  become  united.  No  cartilage 
cells  could  be  found;  the  union  of  graft  to  spinous  process  was 
by  new  bone  formation. 

Experiment  2. — January  IS,  1912.  Dog,  terrier,  male,  mon- 
grel; weight,  20)^  lb.  Ether  anaesthesia.  Assistant,  Dr. 
Keller.  Precisely  the  same  technique  was  carried  out  in  this 
case  as  in  Experiment  No.  1,  except  that  the  whole  diameter  of 
the  shaft  of  the  ulna  was  removed  subperiosteally.  A  sharp 
periosteal  elevator  was  used,  and  the  periosteum  was  removed 
from  the  bone  with  force  for  the  purpose  of  being  certain  of 
separating  the  deep  osteogenetic  layers  from  the  bone  cortex 
and  obtaining  it  as  a  part  of  the  periosteum.  The  periosteum 
was  left  171  situ  in  the  leg.  The  transplant  was  inserted  by  the 
same  technique  as  in  Experiment  No.  1,  except  that  the  perios- 
teum had  been  removed  as  just  described.  The  leg  and  back 
wounds  were  closed  by  continuous  sutures  of  linen.  The 
periosteal  tube  was  allowed  to  collapse. 

January  22,  back  wound  septic.  January  28,  leg  wound 
healed  by  primary  union. 

Necropsy. — February  29,  1912.  Back  wound  was  septic; 
graft  had  sequestrated.  It  is  believed  that  the  difficulty  in 
preparing  the  dog's  skin  for  operation,  in  addition  to  large 
hsematomata  which  invariably  collect  in  the  loose  areolar  tissue 
of  the  dog's  back,  in  spite  of  all  precautions,  was  largely  re- 
sponsible for  the  sepsis  in  the  back  wound,  since  at  the  same 
time  the  leg  wounds  were  clean.  The  conditions  about  the 
back  wound  were  precisely  the  same  as  those  in  Experiment  1, 
namely,  a  deposit  of  osteoid  tissue  in  the  wall  of  the  sequestrum 
pocket;  the  graft,  however,  had  sequestrated. 

In  the  foreleg,  a  bridge  of  bone  had  appeared  where  the  shaft 
of  the  ulna  had  been  removed.  In  the  centre,  it  tapered  to  a 
diameter  about  half  that  of  the  original  bone.  This  bone  growth 
had  been  very  rapid,  and  connected  the  ends  of  the  ulna. 

Experiment  3. — January  23,  1912.  Dog,  terrier,  female; 
weight,  22  lb.  Ether  anaesthesia.  Anaesthetist,  Mr.  Cas- 
sellius.     Assistant,   Dr.   Keller.     The  spinous  processes  of  the 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


111 


last  two  thoracic  and  first,  second,  and  third  himbar  vertebrae 
were  prepared  as  usual  for  the  graft.  With  chisel  and  mallet 
and  saw,  about  1^4  in.  of  the  left  ulna  were  removed,  leaving 
the  periosteum  from  half  its  diameter  in  situ  in  the  leg.     In 


J  \^'  '*'■> 


te'-^r '^ 


D 


Fig.  63. — Longitudinal  section  through  spinous  process  with  cross-section  of  graft 
(ABC)  which  had  been  inserted  6  months;  from  a  low-power  photomicrograph  of  a 
non-decalcified  ground  specimen.  Numerous  blood-ve-sels  can  be  seen,  under  high 
magnification,  extending  from  spinous  process  into  graft.  D  is  new  bone.  E  is  base  of 
spinous  process. 

this  instance,  the  periosteum  which  was  removed  was  separated 
with  the  blunt  end  of  a  pair  of  scissors  so  that  no  force  was  em- 
ployed in  scraping  it  from  the  bone;  it  peeled  off  easily.  The 
portion  of  the  ulna  which  had  been  removed  was  then  split 


112  BONE-GIIAFT    SURGERY 

lonsitiidiiuilly  with  a  chisel  into  equal  parts,  one-half  being  cov- 
ered with  periosteum.  This  fragment  was  inserted  into  the  last 
two  thoracic  vertebrae.  The  fragment  from  which  the  perios- 
teum had  ])een  removed  was  inserted  into  the  second  and  third 
lumbar  vertebras. 

Necropsy. — February  29,  1912.  The  posterior  end  of  the 
w^ound  was  filled  with  pus ;  the  anterior  end  had  healed  by  granu- 
lation. The  graft  from  which  the  periosteum  had  been  re- 
moved, and  which  had  been  placed  in  the  lunil)ar  vertebrae, 
had  sequestrated  and  was  surrounded  with  pus.  The  graft 
insert  which  was  placed  in  the  thoracic  vertebrae  was  firmly 
united  into  those  vertebrae.  A  microscopic  examination  showed 
the  union  to  be  bony.  No  evidence  of  degeneration  or  cellular 
death  could  be  found.  No  bone  or  evidence  of  osteogenesis 
appeared  between  the  ends  of  the  vdna  where  the  graft  had 
been  obtained  except  about  the  bone  ends.  The  periosteum, 
in  this  case,  as  stated,  was  removed  from  the  bone  by  means  of 
a  blunt  instrument  and  with  no  effort  to  get  into  a  deep 
cleavage. 

Experiment  4. — January  25,  1912.  Dog,  mongrel,  female. 
Ether  anaesthesia.  Anaesthetist,  Mr.  Cassellius.  Assistant, 
Dr.  Soule.  On  the  evening  before  the  operation,  the  dog  re- 
ceived a  bath  in  2  per  cent,  aqueous  solution  of  liquor  cresolis 
compositum.  In  the  following  experiments  this  bath  was  given. 
Two  inches  of  the  shaft  of  the  left  ulna  were  removed  subperi- 
osteally.  A  sharp  periosteal  elevator  was  used  for  the  purpose 
of  getting  into  deep  cleavage.  The  portion  of  the  ulna  shaft 
removed  was  then  split  longitudinally  with  a  chisel  and  mallet 
into  halves.  One  of  the  bone  fragments  was  inserted  by  the 
usual  technique  into  the  last  thoracic  and  first  and  second 
lumbar  vertebrae.  The  remaining  bone  fragment  was  placed 
in  sterile  normal  salt  solution  in  an  ordinary  ice-box  for  the 
purpose  of  transplanting  it  into  the  next  dog  operated  on. 
Wounds  healed  by  primary  union. 

Necropsy. — May  9,  1912.  The  transplant  was  found  to  be 
firmly  united  with  the  spinous  processes.     The  graft  had  lost 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


113 


its  identity.     From  the  appearance  of  the  bridge  of  bone  be- 
tween the  tips  of  the  three  spinous  processes  one  could  not  say 


.\:ih   iJ-^lf^^\.  ■■■'    ■•.^.::-.v" 


r^ 


Fig.  64. — Photomicrograph  of  section  through  the  long  axis  of  spinous  process  of  a 
dog  with  a  cross-section  of  an  autogenous  ulnar  graft  (abc)  thoroughly  united  by  new 
bone  2  months  after  the  graft  was  inlaid  into  the  split  tips  of  three  spinous  processes. 
The  analogy  to  the  technique  of  the  tree  graft  (Fig.  5)  is  apparent.  A  careful  micro- 
scopic study  of  this  section  has  failed  to  disclose  dead  bone-cells.  The  corners  of  the 
graft  are  indicated  by  a,  b,  and  c.  d  indicates  base  of  spinous  process.  The  author's 
surgical  experience  in  over  2.50  cases,  as  well  as  a  large  amount  of  animal  experimental 
work,  has  convinced  him  that  the  inlay  method  of  insertion  affords  by  all  means  the 
most  favorable  graft  en\'ironment,  as  this  and  many  other  microscopic  sections  have 
proved. 

from  what  it  liad  originated.  Alicroscopic  examination  showed 
bony  union  of  graft  to  spinous  process  and  no  evidence  of  cellular 
degeneration.     A  strong  bridge  of  bone  was  present  between  the 


114 


BONE-GKAFT   SURGERY 


ulnar  ends,  filling  in  the  space  where  the  transplant  had  been 
removed.  This  bridge  of  bone  was  not  quite  so  large  in  diame- 
ter as  th(^  normal  ulnar  shaft.  It  was,  however,  sufficiently 
strong  for  functional  purposes.  It  is  believed  that  the  satis- 
factory osteogenesis  obtained  in  this  case  as,  for  instance,  com- 
pared with  practically  no  bone  growth  in  Experiment  3,  was 


Fig.  65.- — Junction   of   graft   and   spinous  process   (AB).      The  transplant    had  been 
inserted  4  months  (Experiment  5).     From  a  high-power  photomicrograph. 


due  to  the  method  of  removing  the  periosteum  by  a  sharp  instru- 
ment for  the  purpose  of  getting  into  deep  cleavage.  In  this  way 
the  chances  are  large  that  the  very  active  osteogenetic  layer  of 
cells,  which  is  situated  on  the  surface  of  and  considerably  ad- 
herent to  the  compact  bone,  will  be  loosened  either  entirely  or 
partly,  and  will  separate  off  as  a  part  of  the  periosteum. 


pott's  disease  and  other  spinal  lesions  115 

Experiment  5. — January  30,  1912.  Dog,  black  hound,  male. 
Ether  anaesthesia.  Anaesthetist,  Mr.  Cassellius.  Assistant,  Dr. 
Soule.  Incision  was  made  over  the  last  three  thoracic  and  first 
three  lumbar  vertebrae.  The  spinous  processes  of  the  three 
lumbar  vertebrae  were  split  into  right  and  left  halves  with  a 
chisel,  and  the  bone  fragment  2  in.  long,  which  had  been  removed 
from  the  dog's  ulna  in  Experiment  4,  January  25,  1912,  and  kept 
in  normal  salt  solution  in  an  ice-box,  was  inserted  into  the  pre- 
pared lumbar  vertebrae.  The  spinous  processes  of  the  tenth  and 
eleventh  thoracic  vertebrae  were  denuded  of  periosteum  with  a 
blunt  instrument  from  the  neural  arches  anteriorly  to  the  tips 
of  the  spinous  processes.  The  separated  ends  of  the  periosteum 
were  then  held  in  approximation  by  linen  sutures.  The  skin 
was  sutured  by  the  subcutaneous  method.  In  all  previous  cases 
the  skin  was  closed  with  the  ordinary  through-and-through 
stitch;  all  succeeding  wounds  were  closed  with  the  subcutaneous 
suture,  resulting  in  much  less  skin  infection. 

Necropsy. — May  8,  1912.  The  transplant  was  amalgamated 
into  the  spinous  processes  and  had  nearly  lost  its  identity.  It 
showed  the  contour  of  the  graft  on  one  end.  From  the  appear- 
ance of  the  bridge  of  bone,  one  would  not  have  thought  that  it 
was  due  to  a  bone  transplant.  There  were  only  a  few  small  dis- 
connected plaques  of  proliferated  bone  from  the  periosteum 
which  had  been  stretched  across  between  the  thoracic  spinous 
processes. 

It  is  thought  that  the  fact  that  there  was  not  a  satisfactory 
bone  growth  from  the  periosteum  may  be  accounted  for  in  two 
ways:  first,  the  periosteum  on  the  spinous  processes  is  meagre 
and  unsatisfactory  on  account  of  so  many  muscular  and  liga- 
mentous attachments;  second,  the  periosteum  was  removed 
with  a  blunt  instrument  without  a  special  effort  being  made  to 
get  into  deep   cleavage. 

Experiment  6. — January  30,  1912.  Dog,  bull,  male;  weight, 
28  lb.  Ether  anaesthesia.  Anaesthetist,  Mr.  Cassellius.  Assist- 
ant, Dr.  Soule.  Incision  was  made  over  and  down  to  the  spi- 
nous processes  of  the  last  two  thoracic  and  first  three  lumbar 


116  BONE-GKAFT    SURGERY 

vertebrae.  Two  and  oiu^-foiirlh  iiichos  of  the  left  ulna  with  its 
periosteum  woi-e  renioA'od  with  saw  and  sj^ht  with  chisel  lon- 
gitudinally into  halves.  These  fragments  of  bone  were  then  in- 
serted into  the  spinous  processes  by  the  usual  technique,  one 
into  the  lumbar  vertebra',  the  othei-  into  the  lower  thoracic.  The 
wounds  healed  by  primary  union. 

The  dog  was  found  dead  on  May  6,  1912.  In  my  absence, 
Mr.  Cassellius  removed  the  operated  portion  of  the  spine  and 
placed  it  in  fixing  solution  for  future  examination.  These 
transplants,  like  all  the  othei"s  in  the  presence  of  asepsis,  had 
become  firmly  united  to  the  sj^inous  processes  into  which  they 
had    been    inserted. 

Experiment  7. — February  1,  1912.  Young  dog,  mongrel 
terrier;  weight,  18  lb.  Ether  anaesthesia.  Anaesthetist,  Mr. 
Cassellius.  Fields  of  operation  prepared  by  iodine  method. 
An  incision  over  the  last  three  thoracic  and  first  three  lumbar 
vertebrae  was  made.  The  lumbar  spinous  processes  were  split 
longitudinally  on  the  left  side  of  their  centre  down  to  the  neural 
arches.  Wound,  as  usual,  packed  with  hot  saline  compress. 
One  and  three-fourths  inches  of  diaphysis  of  left  ulna  were  re- 
moved subperiosteally.  A  blunt  instrument  was  used  to  separate 
the  periosteum  which  was  left  in  situ  in  leg.  One-half  of  the 
ulnar  shaft  was  placed  by  the  usual  technique  into  the  posterior 
lumbar  vertebrae.  Pieces  of  periosteum  stripped,  without  aid 
of  a  sharp  instrument,  from  the  ulna,  varying  in  size  from  one- 
fourth  by  one-fourth  of  an  inch  to  small  bits,  were  sutured  into 
the  belly  of  the  muscle,  which  had  been  turned  aside  when  the 
ulnar  shaft  was  removed.  The  muscle  was  then  sutured  into  its 
normal  position.  The  periosteum  on  the  left  side  of  the  two 
anterior  spinous  processes  was  stripped  and  retained  in  two 
pieces  with  some  difficulty.  These  periosteal  flaps  were  then 
drawn  together  and  sutured,  thus  producing  a  periosteal  bridge 
between  these  processes.  The  remaining  half  of  the  ulna  was 
placed  in  salt  solution  for  the  purpose  of  transplanting  it  into  the 
next  dog  operated  on. 

Necropsy. — At  necropsy,  3  months  later,  the  transplant  was 


pott's  disease  and  other  spinal  lesions  117 

firmly  united  into  the  spinous  processes.  No  osseous  tissue 
could  be  found  as  a  development  from  the  periosteal  bridge 
between  the  spinous  processes.     Only  a  small  plaque  of  new  bone 


'  /^ 


-^'      ;>- ^- '^'\^^    • -^^    ■   *♦    ■-■■■ 


. '-  .■■■  •■•;^'^."-7^^' 


Fig.  66. — Decalcified  section  through  long  axis  of  spinous  process  with  cross-section 
of  the  grown-in  graft,  6  months  after  a  portion  of  same  animal's  ulna  had  been  grafted 
into  spinous  processes.  A  careful  microscopic  study  of  these  sections  and  all  others 
has  failed  to  disclose  dead  bone-cells.  The  corners  of  the  graft  are  indicated  by  a,  b 
and  c  (d  is  a  microtome  artefact) ;  e  is  base  of  spinous  process. 

could  be  found  where  the  ulna  had  been  resected.     There  was 
new  growth  of  bone  about  the  cut  ends  of  the  ulna. 

Experiment  8. — Dog.     Ether  anaesthesia.     Ansesthetist,   Mr. 
Cassellius.     Assistant,  Dr.  Soule.     The  last  three  thoracic  and 


118  BONE-GRAFT   SURGERY 

first  three  lumbar  processes  were  split  as  usual.  Numerous 
slivers  of  the  previous  dog's  ulna,  devoid  of  periosteum,  were 
placed  between  the  split  portions  of  the  two  upper  thoracic  ver- 
tebrae. The  supraspinous  and  interspinous  ligaments  were 
drawn  over  in  the  same  way  as  when  a  large  graft  was  used. 
All  the  ligaments  and  muscles  were  separated  from  the  second 
and  third  lumbar  spinous  processes  for  about  two-thirds  of  an 
inch  from  their  tips.  These  two  spinous  processes  were  then 
split  longitudinally  into  equal  anterior  and  posterior  portions. 
Green-stick  fractures  were  produced  in  the  anterior  half  of  the 
posterior  process  and  the  posterior  half  of  the  anterior  process. 
The  tips  of  these  fragments,  well  denuded  of  periosteum  and 
soft  tissues,  were  then  contacted  and  held  with  a  linen  ligature. 
The  ligaments  and  fascia  were  drawn  over  all  with  a  continuous 
linen  suture.  The  skin  was  closed  as  usual  with  a  subcutaneous 
continuous   suture. 

Necropsy. — At  necropsy,  2^2  months  later,  there  was 
evidence  of  some  skin  infection  which  had  nearly  subsided. 
The  slivers  of  bone  had  united  and  produced  a  bridge  of  bone 
between  the  spinous  processes,  but  not  so  firm  as  one  resulting 
from  one  large  graft.  There  was  no  bony  union  between  the 
approximated  fragments  of  the  second  and  third  lumbar  spinous 
processes. 

Experiment  9. — Dog,  terrier,  male;  weight,  183^  lb.  Prepa- 
ration: bath  in  compound  solution  of  cresol,  and  shaving,  the 
night  before  operation.  The  field  of  operation  was  allowed  to 
dry  over  night  and  treated  with  American  tincture  of  iodine 
just  before  operation.  This  preparation  was  used  in  all  of  the 
succeeding  cases  and  was  found  very  satisfactory.  Ether  anaes- 
thesia. Assistant,  Dr.  Soule.  Site  in  back  for  graft  was  pre- 
pared as  in  previous  cases  and  packed  with  saline  compress.  Two 
inches  of  middle  of  left  ulna  were  removed  subperiosteally  with 
blunt  dissector.  This  portion  of  the  ulna  was  then  split  longi- 
tudinally into  quarters,  two  of  which  were  placed  in  the  tips  of 
three  lumbar  vertebrae.  A  strip  of  periosteum  1}4  in.  by  H  in., 
taken  from  the  ulna  by  a  blunt  dissector,  was  placed  into  the 


pott's  disease  and  other  spinal  lesions  119 

tips  of  two  split  spinous  processes  anterior  to  those  that  contained 
the  graft  previously  inserted.  The  periosteum  was  placed  in 
a  similar  manner  to  that  of  the  bone  graft.  The  back  wound  was 
closed.  Two  pieces  of  bone  I4  in.  by  I4  in.  by  1^  in.  in  diam., 
which  had  been  taken  from  the  tip  of  a  spinous  process  of  the 
same  dog,  were  placed  in  the  belly  of  a  muscle  in  the  left  fore- 
leg. Two  pieces  of  bone  of  the  same  size  were  taken  from  the 
ulna  and  placed  in  the  belly  of  another  muscle  in  the  left  foreleg, 
the  object  being  to  determine  which  was  the  more  osteogenetic. 

The  dog  was  found  dead  February  27,  1912. 

Necropsy. — February  28,  1912.  Assistant,  Dr.  Soule.  The 
bone  transplant  was  found  firmly  united  by  callus  to  those  spi- 
nous processes  into  which  it  had  been  inserted.  The  graft 
presented  every  appearance  of  being  live  bone.  The  small 
pieces  of  bone  from  the  tip  of  a  spinous  process,  which  had  been 
implanted  into  a  muscle  belly  at  operation,  had  changed  very 
little;  there  was  a  very  small  proliferation  on  the  side  of  the 
periosteum.  The  pieces  of  bone  taken  from  the  ulna  and  inserted 
into  a  muscle  belly  had  also  changed  very  little.  There  was, 
however,  considerable  proliferation  on  the  side  of  the  periosteum. 
The  piece  of  periosteum  (li:^  in.  by  }i  in.),  which  had  been  placed 
between  the  tips  of  two  split  spinous  processes,  presented  no  evi- 
dence of  proliferation  and  was  difhcult  to  find. 

Experiment  10. — February  13,  1912.  Puppy,  terrier.  Ether 
anaesthesia.  Assistant,  Dr.  Soule.  An  incision  5  in.  long  w^as 
made  over  and  down  to  the  tips  of  the  last  thoracic  and  first 
three  lumbar  vertebrae.  Interspinous  ligaments  split  with  scal- 
pel, spinous  process  with  chisel.  A  piece  of  the  ulna  of  the  dog 
previously  operated  on  (m  in.  long  and  one-half  the  diameter 
of  the  bone)  was  inserted,  by  the  technique  already  described, 
into  the  spinous  processes  of  the  second  and  third  lumbar 
vertebrae.  A  piece  of  the  same  dog's  left  ulna  of  about  the 
same  size  was  then  removed  subperiosteally  with  chisel  and 
saw  and  inserted  into  the  last  thoracic  and  first  lumbar  verte- 
brae. A  piece  of  periosteum  (I14  in.  by  }i  in.),  removed  by 
blunt  dissection  from  the  ulna,  was  placed  into  the  fascia  l}y^ 


120 


BONE-GRAFT    SUHCiEHV 


in.  to  the  left  of  the  first  kimbar  vertebra  and  fixed  with  Hnen 
sutures.  On  the  opposite  side  (right),  and  in  the  same  relation 
to  the  first  lumbar  vertebra,  a  piece  of  the  left  ulna  {H  in.  by  3^ 
in.)  was  placed  in  the  same  manner  as  the  periosteum.  The 
right  foreleg  was  broken  o\'er  the  side  of  a  table  and  a  splint 


t0> 


s  '•»  i  :^r 


y^i^r 


^*'  V>  ^'^'' 


'^j; 


:>.    V 


^^ 


Fig.  67. — Junction  of  graft  and  spinous  process  in  a  case  of  6  months  (Experiment  1). 
No  dead  bone-cells  could  be  found  in  these  specimens.  From  a  high-power  photo- 
micrograph. 

was  applied,  in  order  to  obtain  thickened  proliferating  periosteum 
for  grafting  purposes  in  10  days'  time. 

Necropsy. — February  27,  1912.  Both  pieces  of  bone,  the  one 
from  another  dog  and  the  one  from  the  same  dog,  were  equally 
firmly  united  into  the  spinous  processes.  A  careful  microscopic 
examination  of  sections  made  through  graft  at  various  places, 
and  through  junction  of  union  of  graft  to  spinous  process,  failed 


pott's  disease  and  other  spinal  lesions  121 

to  show  any  evidence  of  degenerated  bone-cells.  The  periosteum 
inserted  into  the  fascia  to  the  left  of  the  spine  presented  no  evi- 
dence of  proliferation,  either  periosteal  or  bone.  The  bone 
placed  under  similar  conditions  to  the  right  of  the  spine  showed 
considerable  proliferation,  especially  on  the  periosteal  side. 

Experiment  11. — February  15,  1912.  Puppy,  male  mongrel; 
weight,  17^4  lb.  Ether  anaesthesia.  Assistant,  Dr.  Soule. 
The  shaft  of  the  left  ulna  was  removed  with  its  periosteum 
intact  and  placed  in  normal  salt  solution,  to  be  kept  in  the  ice- 
box for  a  following  case.  The  spinous  processes  of  the  last  tho- 
racic and  first  lumbar  vertebrae  were  prepared  as  usual  and  a  piece 
of  a  puppy's  ulna  (one-half  its  diameter  and  1-^4  in.  long),  which 
had  been  removed  2  days  previously  and  kept  in  Ringer's  solu- 
tion in  an  ice-box,  was  inserted  by  the  usual  technique  into 
the  second  and  third  lumbar  vertebrae.  A  fragment  of  ulna 
with  periosteum  of  approximately  the  same  size,  which  had  been 
removed  from  an  old  dog  2  days  previously  and  kept  in  salt 
solution  in  an  ice-box,  was  inserted  into  the  last  two  thoracic 
vertebrae. 

Necropsy. — Six  weeks  from  time  of  operation.  Both  bone 
grafts  were  found  firmly  united  into  the  spinous  processes.  X- 
rays  taken  in  different  planes  of  specimens  (see  Fig.  68)  failed 
to  show  any  areas  of  degeneration  in  the  graft.  Both  decalcified 
and  non-decalcified  (ground)  microscopic  specimens  were  pre- 
pared and  examined  carefully.  No  dead  bone-cells  could  be 
found.  The  graft,  although  only  6  weeks  after  insertion,  was 
very  completel}^  united  into  the  spinous  processes  by  newly 
formed  bone.     No  cartilage  cells  could  be  found. 

Experiment  12. — February  20,  1912.  Dog.  Ether  anaes- 
thesia. Anaesthetist,  Mr.  Cassellius.  An  incision  3  in.  long 
was  made  over  the  lower  three  thoracic  spinous  processes.  The 
muscles  and  ligaments  with  periosteum  were  separated  from 
them  down  to  the  neural  arches,  and  retracted.  The  processes 
were  divided  at  their  base  with  bone  forceps  and  chisel  close  to 
the  neural  arches.  The  processes  were  then  placed  longitudi- 
nally so  that  the  tip  of  one  process  came  into  approximation 


122  BONE-GRAFT   SURGERY 

with  the  severed  base  of  the  next  superior  process.  The  soft 
tissues  with  periosteum  were  brought  back  with  interrupted 
sutures  of  Unen.  The  skin  was  closed  with  subcutaneous  hnen 
suture.  The  second  and  third  hiinbar  processes  were  then  ex- 
posed. Their  tips  were  split  in  the  usual  manner  for  two-thirds 
of  an  inch  in  situ,  with  supraspinous  and  interspinous  Hga- 
ments  undetached.  A  fragment  of  an  ulna  removed  from  a  dog 
1  week  previously,  and  kept  meantime  in  normal  salt  solution 
in  an  ice  box,  was  inserted  as  a  graft  by  the  usual  technique. 
This  transplant  was  1^^  in,  long  and  one-half  the  diameter  of 
the  ulnar  shaft.  The  skin  was  closed  by  subcutaneous  sutures 
of  linen. 

Necropsy. — Two  and  one-half  months  after  operation.  Bony 
union  had  not  occurred  between  the  thoracic  vertebrae  whose 
spinous  processes  had  been  broken  down.  It  should  be  stated, 
however,  that,  as  in  all  other  cases,  no  attempt  to  fix  or  immobil- 
ize the  dog's  spine  was  made.  The  graft  which  had  been  inserted 
into  the  second  and  third  lumbar  processes  was  well  united. 

Experiment  13. — April  24, 1912.  Dog,  mongrel,  male;  weight, 
21}^  lb.  This  experiment  was  possible  only  through  the  kind- 
ness of  Drs.  Beebe  and  Berkeley,  who  allowed  me  to  remove  a 
part  of  a  sheep's  ulna  while  Dr.  Berkeley  was  operating  on  it. 
A  fragment  of  ulna  3)^  in.  by  1 3  in.,  including  periosteum  as  well 
as  marrow  substance,  was  removed  from  a  large  sheep  and  placed 
in  normal  salt  solution  until  the  dog's  spinous  processes,  three  in 
number  (first  thoracic  and  first  and  second  lumbar),  could  be 
split  and  prepared  in  the  usual  way.  The  transplant  was  then 
inserted  and  covered  with  the  ligaments  as  already  described. 

Necropsy. — Five  weeks  after  operation.  Although  the  wound 
had  healed  kindly  by  primary  union,  the  transplant  was  found  in 
a  pocket  filled  with  serum.  No  evidence  of  osteogenesis  on  the 
part  of  the  graft  or  union  to  spinous  processes  was  present. 

The  following  deductions  and  conclusions  are  based  on  the 
experimental  work  just  described,  in  conjunction  with  a  clinical 
experience  gained  from  500  bone-grafting  operations  on  the 
human  subject:    In  ten  of  the  cases  of  Pott's  disease  the  bone 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


123 


A-' 


<-B 


•MMMT 


A 


/" 


Fig.  68. — Photograph  and  rontgenograms  of  aia  uhia  autogenous  graft  AB,  6  weeks 
after  being  inserted  into  the  spinous  processes  of  a  dog's  vertebrae.  The  rontgenograms 
show  firm  union  and  no  osteoporosis  or  degeneration  of  the  graft. 


124  BONE-GRAFT    SURGERY 

transplant  has  been  cut  down  on  for  minor  reasons,  inspected, 
and  parts  removed  for  examination.  The  time  after  operation 
has  been  3,  5  and  7  weeks,  G  months,  and  1  year.  In  all  of  these 
cases  the  grafts  have  been  well  united  into  the  spinous  processes 
wherever  contacted.  In  two  cases  the  end  of  the  graft  had  sprung 
posteriorly  into  the  soft  tissues.  In  every  instance  the  portion 
of  the  graft  which  was  contained  in  the  spinous  processes  bled 
wherever  cut  with  bone  forceps;  its  periosteum  had  proliferated 
and  the  transplanted  portion  presented  every  appearance  of 
viability.  On  the  other  hand,  in  two  cases  the  portion  of  the 
graft  projecting  into  the  soft  tissues  was  pale,  and  the  periosteum 
had  not  proliferated;  the  bone  did  not  bleed  in  its  central  por- 
tion when  cut  and  was  thought  to  be  acting  as  an  ''osteogenetic 
scaffold,"  whereas  there  seemed  every  reason  to  believe,  espe- 
cially in  the  light  of  our  microscopic  results,  that  the  portion  in  and 
between  the  spinous  processes  was  viable,  on  account  of  the  con- 
tacted points  of  Haversian  blood  supply  being  so  numerous  and 
near  together. 

SUMMARY 

1.  Many  liberties  may  be  taken  with  the  bone  graft  without 
interfering  with  its  success.  It  has  certain  bacteria-resisting 
properties.  In  one  case  the  transplant  was  kept  in  normal  salt 
solution  in  an  ice-box  for  1  week,  and  in  others  for  shorter  periods, 
and  successful  results  followed.  In  two  cases  sepsis  occurred  in 
the  same  wound;  nevertheless,  parts  of  the  graft  in  each  case 
became  united  to  the  recipient  bone  and  remained,  while  the  rest 
of  the  transplant  sequestrated.  From  these  experiences  and  the 
fact  that  in  the  author's  series  of  500  bone-grafting  procedures 
on  human  subjects  only  parts  of  eight  grafts  and  two  whole 
grafts  sequestrated,  it  is  believed  that  one  is  safe  in  deducing 
that  the  bone  graft  has  considerable  germ-resisting  properties. 

2.  It  seems  very  probable  that  the  amount  of  Haversian 
blood  supply  is  in  a  very  large  degree,  if  not  wholly,  responsible 
in  determining  whether  the  bone  graft  lives  as  such  or  acts  as  an 
osteoconductive   scaffold.     This  was  especially  emphasized   in 


pott's  disease  and  other  spinal  lesions  125 

the  three  human  cases  cut  down  upon.  If  the  graft  is  to  hve  as 
such,  the  blood-supply  contacts  must  be  of  favorable  character 
and  numerously  distributed  along  its  whole  extent,  such  as  is 
the  case  with  the  spine  graft  or  the  transplant  used  for  ununited 
fractures,  described  elsewhere. 

3.  The  bone  transplant  apparently  acts  always  as  a  stimu- 
lant to  osteogenesis  on  the  part  of  the  bone  into  which  it  has 
been  implanted. 

4.  The  spinal  graft  in  the  dog  loses  its  identity  at  about  the 
fourth  month.  After  that  time,  one  would  not  know  from  its 
appearance  that  the  bone  bridge  had  originated  in  this  way. 

5.  Bone  taken  from  another  species,  such  as  the  sheep,  did 
not  unite  to  the  recipient  bone  of  the  dog,  although  in  the 
presence  of  asepsis.  This  one  experiment  does  not  prove  that 
sheep's  bone  will  not  unite  to  dog's  bone  as  a  graft,  but  it  does 
prove  the  unreliability  of  the  procedure. 

6.  A  bone  bridge  between  different  vertebrae  was  accom- 
plished in  this  small  series  of  experiments  only  by  the  bone 
graft.  Breaking  down  the  spinous  processes,  splitting  the 
spinous  processes  with  approximation  to  the  contiguous  halves, 
and  the  insertion  of  periosteal  bridges  failed  to  produce  the  de- 
sired continuous  bone  bridge. 

7.  Bone  transplants  taken  from  a  long  bone,  such  as  the  ulna, 
showed  evidence  of  greater  osteogenesis  than  when  taken  from 
the  spinous  processes. 

8.  Bone  from  which  the  periosteum  had  been  removed  proved 
equally  satisfactory  to  bone  grafts  on  which  the  periosteum 
had  been  retained,  but  their  persistency  was  not  tested  because 
the  animals  w^ere  not  allowed  to  live  long  enough.  It  seems 
certain  that  the  fate  of  a  bone  graft  depends  largely  on  its  exact 
environment,  especially  as  to  the  numerous  bone  contacts  closely 
situated. 

9.  The  above-mentioned  germ-resisting  property  of  the  bone 
graft,  in  addition  to  its  early  adhesion  by  bone  growth  to  the 
bones  with  which  it  is  contacted,  in  the  author's  opinion,  favors 
its    substitution,  when  feasible,  in  place  of  all-metal  internal 


126  BONE-GRAFT    SURGERY 

splints,  especially  when  it  is  considered  that  the  metal  splint 
has  absolutely  the  opposite  influence,  namely,  the  pi-oduction 
of  bone  absorption,  and  that  it  favors  infection. 

11.  It  also  seems  that  it  is  largely  a  question  of  definition 
of  what  the  periosteum  is  and  what  it  includes  as  to  whether 
it  is  to  be  actively  osteogenetic  or  not.  If  by  chance  the  cleav- 
age is  deep,  as  when  the  periosteum  is  removed  with  a  sharp 
elevator  and  the  bone  scraped,  the  periosteum  is  sure  to  be 
actively  osteogenetic.  On  the  other  hand,  if  the  periosteum 
is  stripped  off  or  removed  with,  a  blunt  instrument,  the  cleavage 
is  not  likely  to  be  deep  enough  to  include  the  osteogenetic 
layer  of  cells  on  the  periphery  of  the  compact  bone.  In  that 
case  the  periosteum  would  be  incomplete  and  would  constitute 
a  connective-tissue-limiting  membrane  (Macewen)  only,  and 
slight  or  no  osteogenesis  would  occur. 

12.  It  is  believed  that  periosteum  and  marrow  substance, 
on  the  bone  graft,  serve  an  important  role  in  aiding  to  establish 
an  early  and  more  abundant  blood  supply  from  recipient  bone  to 
the  transplant. 

PARALYTIC  SCOLIOSIS 

Paralytic  scoliosis  usually  results  from  the  unbalancing  of 
the  spinal  column  through  asymmetrical  involvement  of  the 
spinal  and  abdominal  groups  of  muscles  from  anterior  polio- 
myelitis. The  selection  of  the  motor  nerve  cells  of  the  anterior 
horns  of  the  spinal  cord  which  supply  these  spinal  muscles  is 
comparatively  rare,  excepting  where  there  is  a  very  general  cord 
involvement.  The  conduct  of  this  affection  is  the  same  when  the 
groups  of  spinal  muscles  are  attacked  as  when  the  disease  has  re- 
sulted in  the  paralysis  of  extremity  muscle  groups. 

This  deformity  is  a  variable  one,  the  severity  of  the  lateral 
deviation  depending  largely  upon  the  posture  of  the  patient 
when  in  the  erect  or  reclining  position.  The  lateral  deviation 
always  diminishes  in  recumbency  and  increases  in  a  varying 
degree  in  the  erect  posture,  according  to  the  severity  of  the 
paralysis.     A  certain  degree  of  rotation  of  the  vertebrae  is  always 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


127 


present,  varying  in  amount  also  with  the  severity  of  the  paraly- 
sis, but  rarely  reaching  the  same  degree  of  rotation  met  with  in 
static  scoliosis. 

The  general  rules  of  treatment  applying  to  all  types  of  in- 

f 


Fig.  69. — Specimen  of  a  pronounced  scoliosis  of  the  spine  which  shows  the  atrophy 
and  approximation  of  the  lateral  processes  of  the  concave  side,  with  an  equal  separation 
of  the  lateral  processes  of  the  convex  side  of  the  curvatures.  If  this  curve  is  straightened 
it  causes  the  lateral  processes  of  the  convex  side  to  approximate  at  the  same  time  that 
those  on  the  concave  side  separate.  Therefore,  if  a  graft  is  placed  on  the  convex  side  in 
the  tips  of  the  lateral  processes  of  a  straightened  paralytic  or  static  scoliotic  spine,  it  is 
under  the  same  mechanical  advantage  as  the  graft  inserted  into  the  spinous  processes 
for  Pott's  disease.      (See  Fig.  70  for  drawing.) 

fantile  paralysis  should  be  carried  out  during  the  initial  febrile 
stage — ^namely,  restraint  in  bed  or  on  a  gas-pipe  frame,  to  re- 
strict motion  of  the  vertebrae  of  the  involved  area  of  the  spine. 
Following  the  febrile  stage,  external  supports,  such  as  plaster- 
of-Paris  corsets  and  metal  frame   braces,  should  be   applied, 


128  BONE-GRAFT   SURGERY 

too'other  with  corrective  p;ymnastic  exercises,  until  no  further 
inii)rovemeiit  can  be  attained,  thus  indicating  that  the  paralysis 
still  persists  and  the  spinal  deviation  therefrom  is  a  result  of 
permanently  destroyed  niotoi-  nerve-cells. 

It  is  difficult  to  maintain  a  correction  of  this  spinal  deviation 
in  the  severer  cases  by  any  external  appliance,  because  the  spine 
slumps  into  an  S-curve  inside  of  the  brace,  due  to  the  lack  of 
muscle  support,  whenever  the  patient  assumes  the  erect  posture. 
After  a  lapse  of  2  years  it  devolves  upon  the  surgeon  to  decide 
whether  the  muscle  weakness  and  the  resulting  curvature  war- 
rant the  implantation  of  the  more  corrective  and  trustworthy 
bone-graft  support. 

Mechanics  of  Correction  by  the  Bone  Graft. — The  bone 
graft  can  be  applied  in  two  ways,  either  by  the  same  technique 
as  the  author's  operation  for  Pott's  disease,  or  by  the  placing  of 
the  graft  into  the  tips  of  the  transverse  processes  of  the  vertebrae 
on  the  convex  side  at  the  apex  of  the  sharpest  curve,  preference 
being  given  to  the  thoracic  region  for  the  implant  and  six  to 
eight  transverse  or  spinous  processes  included  by  this  graft. 

From  a  mechanical  standpoint,  the  transverse  processes  afford 
a  much  better  leverage  action  to  the  correction  of  the  lateral 
curvature  than  the  spinous  processes.  A  lateral  deviation  in 
the  spine  causes  a  separation  of  the  transverse  processes  of  the 
convex  side,  coincident  with  the  approximation  of  the  trans- 
verse processes  of  the  concave  side.  Much  of  this  lateral  de- 
formity can  be  readily  corrected  by  manual  force  under  an  anaes- 
thetic. This  correction  causes  the  transverse  processes  of  the 
convex  side  to  approach  each  other  at  the  same  time  that  the 
transverse  processes  of  the  concave  side  separate.  The  implan- 
tation of  the  graft  with  the  spine  so  corrected  acts  in  a  like  man- 
ner in  preventing  the  relapse  to  lateral  curvature,  by  controlling 
the  separation  of  the  transverse  processes  of  the  convex  side,  as 
does  the  graft  implanted  into  the  spinous  processes  for  the  con- 
trol of  the  antero-posterior  deformity  of  Pott's  disease.  The 
graft  thus  embedded  acts  at  a  great  mechanical  advantage,  in 
that  it  is  pulled  upon  lengthwise,  in  preventing  the  separation 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


129 


of  the  transverse  processes,  which  are  arms  of  levers,  at  the 
same  time  acting  as  an  internal  fixation  splint. 

Author's  Technique  of    Operation. — A  plaster-of-Paris  bed 
with  firm  lateral  walls  should  be  moulded  before  the  operation  to 


Fig.  70. — Drawing  from  a  scoliotic  spine.  The  lines  indicate  the  axis  of  the  lateral 
process  and  show  how  near  together  they  are  on  the  concave  side  of  the  curve  and  how 
much  .separated  they  are  on  the  convex  side.      (See  Fig.  71.) 

the  back  and  sides  of  the  patient's  trunk,  and  allowed  to  harden 
while  the  patient  is  held  in  the  corrected  position.  The  field  of 
operation  on  the  back,  as  well  as  the  leg,  is  prepared  by  the  iodine 


130 


BONE-GRAFT    SURGERY 


method.     Six  to  eight  transverse  processes  at  the  apex  of  the 
most  acute  curve  are  laid  bare  on  the  convex  side  by  a  curved  skin 


YiG    71  —Drawing  to  illustrate  straightening  of  paralytic  scoliotic  spine  and  the  tibial 
graft  in  place.     (See  Fig.  70,  illustrating  spine  before  correction.) 

incision,  similar  to  the  skin  incision  in  the  bone-graft  operation 
for  Pott's  disease.     The  muscles  and  ligaments  over  the  tips  and 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


131 


between  the  transverse  processes  are  split  into  approximately 
equal  halves  with  a  scalpel.  The  transverse  processes  are  split 
longitudinally  into  halves  and  at  the  same  time  the  posterior 
half  is  set  over  to  give  room  for  the  graft.  With  flexible  probe 
and  calipers  the  contour  and  length  of  the  desired  graft  are  de- 
termined. The  tibia  is  flexed  on  the  thigh  and  its  antero-internal 
surface  laid  bare.  The  flexible  probe  pattern  is  applied  to  this 
exposed  tibial  surface,  and  the  desired  graft  is  outlined  in  the 
periosteum  with  a  scalpel,  its  length  being  determined  by  the 
previous  measurement  with  the  calipers.  The  motor  saw  is  then 
made  to  cut  along  this  periosteal  outline  and  the  graft  is  re- 


FlG. 


72. — To  illustrate  tibial  bone  graft  in  place  in  tips  of  lateral  processes  of  convex 
side  of  a  corrected  paralytic  scoliosis. 


moved,  including  the  full  thickness  of  the  cortex,  and  placed  into 
its  bed  already  prepared  between  the  halves  of  the  split  transverse 
processes.  While  the  patient  is  held  in  the  corrected  position, 
the  ligaments  and  muscles  are  drawn  over  the  graft  with  inter- 
rupted sutures  of  medium  kangaroo  tendon. 

The  wound  is  closed  by  a  continuous  suture  of  No.  1  chromic 
gut,  and  a  generous  dressing  applied.  The  patient  is  bandaged 
into  the  plaster-of-Paris  bed,  previously  prepared  (or  see  Fig.  77). 

After  6  weeks  of  recumbency  in  this  plaster  bed,  a  well- 
moulded  plaster  case  is  applied  to  the  spine  to  remain  on  [for 
10  to  12  weeks.     Following  the  immediate  post-operative  fixa- 


132 


BONE-GRAFT    SUKGERY 


Fig.   73. — A  case  of  paralytic  scoliosis  before  correction  and  insertion  of  graft. 

(See  Fig.  74.) 


Fig.  74. — Paralytic  scoliosis;  same  case  as  Fig.  73,  1  year  after  the  insertion  of  a 
graft  into  the  tips  of  the  transverse  processes  of  the  apex  of  the  convex  side  of  the  worse 
curve.  The  graft  included  the  thoracic  vertebra;  from  the  fifth  to  the  twelfth  inclusive. 
The  marked  straightened  condition  and  increased  stability  of  the  back  is  most  gratifying. 


pott's  disease  and  other  spinal  lesions  133 


Fig.   75. — Paralytic  scoliosis  before  correction  by  the  insertiun  ui  a   Ijuih    jfraft. 

(See  Fig.  76.) 


134 


BONE-GRAFT   SURGERY 


lion,  a  corset  brace  is  applied  to  tliose  cases  which  need  further 
support  supplemental  to  the  j^i'aft. 


^ 


#' 


Fig.   76. — Same  case  as  Fig.  75,  1  year  after  correction  and  insertion  of  bone  graft  for 

paralytic  scoliosis. 


SPONDYLOLISTHESIS 

Spondylolisthesis  is  a  term  applied  to  the  luxation  of  the 
body  of  one  of  the  lower  vertebrae.  The  extent  of  this  luxation 
varies  from  a  slight  displacement  to  a  complete  dislocation,  and 


POTT  S    DISEASE    AND    OTHER    SPINAL    LESIONS 


135 


in  some  cases  the  displaced  vertebral  bod}'  has  slid  down  and 
become  anterior  to  the  vertebral  body  next  below. 

The  condition  was  first  described  by  Killian  in  1854,  and  was 
thoroughly  studied  by  Neugebauer  in  1890.  The  causes  are: 
congenital   malformation,    injury,    and   disease   of   the   lumbo- 


;^m.  .,m^' 


Fig.  77. — Dr.  Silver's  attachment  to  theHawley  table.  Illustrating  the  method  for 
the  application  of  plaster  jackets  by  the  hammock  method,  thus  enabling  the  operator 
to  apply  a  jacket  after  the  operation  on  the  spine  or  back  without  turning  or  moving  the 
patient.  The  hammock  is  laid  upon  the  narrow  portion  of  the  table  with  one  end  slipped 
through  the  special  two-piece  pelvic  support  and  the  patient  is  then  placed  in  the  re- 
versed position,  the  head  and  body  resting  on  the  narrow  portion  of  the  table.  The  other 
end  of  the  hammock  is  slipped  over  the  U-shaped  frame,  which  fits  into  the  foot  exten- 
sion pieces,  but  this  need  not  be  put  in  until  the  operator  is  ready  to  apply  the  cast. 
The  hammock  may  be  readily  tightened  or  loosened  by  moving  the  foot  pieces  on  the 
sliding  bars.  If  desired,  one  or  both  thighs  may  be  included  in  the  cast  by  moving  the 
sliding  platform  far  enough  away  from  the  patient's  bodj\  This  table  is  of  especial 
advantage  in  the  application  of  a  plaster  jacket  after  the  insertion  of  bone  graft  for 
paralytic  scoliosis. 


sacral  articulations.  The  effect  of  the  luxation  is  to  cause  an 
exaggeration  of  the  lumbar  lordosis  and  to  increase  the  promi- 
nence of  the  sacrum.  The  condition  exists  more  often  in  women 
than  in  men. 

It  occurs  almost  always  at  puberty  or  in  early  adult  life,  and 
a  large  percentage  of  all  cases  give  a  history  of  a  severe  trau- 


13G 


BONE-GRAFT    SURGERY 


matisin.     Tlio  displacement  may  follow  immediately  after  the 
accident,  or  may  not  appear  until  a  later  period. 

The  appearance  of  the  patient  is  very  suggestive  of  a  double 
congenital  dislocation  of  the  liips,  altliough  on  closer  inspection 


Fig.  78. — A  case  of  spondylolistliesi.s  in  a  young  man  of  18  following  an  injury 
in  a  prize  fight.  Deformity  reduced  and  reduction  maintained  with  bone  graft.  (See 
Figs.  79,  82.) 


it  is  seen  that  the  back  is  shortened  and  not  the  limbs.  The 
flexibility  of  this  portion  of  the  spine  is  not  impaired,  but  may 
even  be  greater  than  normal. 

The  former  treatment  of  this  condition  has  proven  most 
unsatisfactory.     It  consisted  of  prolonged  rest  in  bed  with  ex- 


pott's  disease  and  other  spinal  lesions  137 

tension  applied  to  the  legs,  followed  by  a  long  plaster-of-Paris 
or  steel  spinal  support,  reaching  well  down  over  the  buttocks. 
In  some  instances,  laminectomies  have  been  performed  in  an 
effort  to  relieve  paralytic  symptoms.  One  such  case  has  been 
reported  by  Arbuthnot  Lane,  of  London.  In  cases  of  great 
deformity,  permanent  support  has  been  necessary. 


Fig.  79. — Illustrating  a  case  of  the  application  of  the  bone  graft  for  marked  spon- 
dylolistheses of  the  lumbar  vertebra  on  the  sacrum.  A  strong  graft  removed  from  the 
tibia  has  fixed  this  segment  of  the  spine  to  the  sacrum  correcting  the  lordosis  and  reliev- 
ing all  symptoms. 


The  bone  graft,  applied  as  for  the  treatment  of  Pott's  dis- 
ease, has  solved  this  hitherto  most  difficult  problem.  The  graft 
is  inserted  by  precisely  the  same  technique  as  that  employed  by 
the  author  for  lumbar  Pott's  disease  (see  Chapter  II).  The 
lordosis,  as  a  rule,  is  readily  corrected  under  an  anaesthetic,  by 
placing  the  patient  in  the  prone  position  on  the  operating  table. 
If  this  should  not  produce  sufficient  correction,  further  flexion 


138 


BONE-GRAFT   SURGERY 


of  the  spine  can  be  accomplished  by  placing  a  firm  pillow  under 
the  lower  portion  of  the  abdomen.  The  bone  graft  offers  the 
only  means  to  effect  a  permanent  cui'o. 


Fig.  80. — -Lateral  roiitgenogram  of  spondylolisthesis  between  the  third  and  fourth 
lumbar  vertebrae  after  reduction  and  fixation  by  author's  spinal  bone  graft  in  spinous 
processes.  The  dislocation  forward  of  the  third  lumbar  vertebra  on  the  fourth,  in  this 
male  patient  of  18  years  of  age,  occurred  in  the  boxing  ring  from  being  knocked  through 
the  ropes.  Pressure  on  the  spinal  cord  resulted  which  has  been  entirely  relieved  by  the 
operation. 

An  illustrative  case  is  that  of  a  young  man,  18  years  of  age, 
who   while   boxing,    II2   years   previously,    sustained   a   severe 


pott's  disease  and  other, spinal  lesions 


139 


injury  to  the  lumbar  spine  by  being  knocked  against  the  ropes — 
a  trauma  which  could  produce  such  a  displacement.  Soon  after, 
the  patient  noticed  muscular  weakness,  numbness,  and  prickly 
sensations  in  the  legs  w^hen  standing  or  walking  for  any  length 
of  time.  These  symptoms  increased  until  he  was  obliged  to 
give  up  his  occupation.  He  also  noticed  the  increasing  deform- 
ity of  his  lumbar  spine.  The  recumbent  position  relieved  his 
symptoms. 


Fig.  81. — Drawing  of  same  case  as  Fig.  80.  The  lateral  rSntgenogram  of  this  case 
before  reduction  and  insertion  of  graft;  although  it  showed  the  luxation,  it  was  so  poor 
that  it  was  unintentionally  destroyed  before  a  print  was  obtained.  This  drawing  is  an 
attempt  to  represent  the  luxation  which  existed. 


Under  full  anaesthesia,  prone  upon  the  operating  table,  the 
displacement  easily  corrected  itself,  and  an  unusually  strong 
graft,  spanning  the  third,  fourth  and  fifth  lumbar  spines,  and  the 
first  and  second  segments  of  the  sacrum,  held  this  portion  rigidly 
fixed  in  its  corrected  position. 

The  patient  was  kept  on  a  fracture  bed  for  5  weeks,  after 
which  a  long  plaster-of -Paris  jacket,  moulded  over  the  buttocks, 
was  applied  to  remain  on  for  2  months  (see  Figs.  79,  82). 


140 


BONE-GRAFT    SURGERY 


Ryerson   has,  also,  reported  a  very  successful  case  treated 
bv  this  method. 


Fig.   82. — Anterior  posterior  view  of  same  case  as  Fig.  SO. 
SPINA  BIFIDA 

In  cases  of  spina  bifida,  where  the  meningocele  has  been 
controlled,  and  a  large  deficiency  of  vertebral  bone  exists,  Jo- 


pott's  disease  and  other  spinal  lesions 


141 


gether  with  weakness,  as  evidenced  by  lordosis  or  other  deformity, 
the  bone  graft  offers  an  excellent  means  for  strengthening 
the  spine  weakened  from  the  congenital  bone  deficiency. 

Author's  Technique. — The  technique  is  somewhat  similar  to 
that  adopted  in  Pott's  disease.  Modification  is  necessary  on 
account  of  the  absence  of  spinous  processes  and  parts  of  neural 
arches.  The  spinous  processes  above  the  cleft  and  the  lateral 
masses  of  the  last  lumbar  vertebrae  and  the  first  part  of  the  sa- 
crum are  reached  from  each  side  by  two  curved  skin  incisions,  as 


Fig.   83. — Drawing  illustrating  author's  technique  of  inserting  a  tibia  graft  to  straighten 
and  support  a  lordotic  bifid  spine  (spina  bifida). 

it  is  undesirable  to  interfere  with  the  nerve  tissue  which  is  usu- 
ally involved  in  the  cicatrix  following  the  operative  reduction  of 
the  meningocele.  The  second  spinous  process  above  the  cleft 
is  split  longitudinally,  and  a  greenstick  fracture  produced  in  each 
half.  The  first  spinous  process  above  the  cleft  is  denuded  of  its 
muscular  and  ligamentous  attachments,  and  both  sides  are 
freshened.  Below  the  cleft,  the  lateral  masses  of  the  fifth  lum- 
bar vertebra  (or  the  congenitally  deformed  stumps  of  the  neural 
arches,  if  sufficiently  prominent)  and  the  first  segment  of  the 


142 


BONE-GRAFT    SURGERY 


sacrum  which  is  usually  coiigeuilally  hypei'troi)hied,  arc  split 
with  the  osteotome,  and  the  halves  are  separated  to  receive  the 
lower  ends  of  the  two  grafts. 

The  wounds  are  packed  with  saline  compresses,  and  the  two 
grafts  are  removed  and  prepared  from  the  crest  of  the  tibia, 
being  long  enough  to  reach  from  the  split  spines  above  to  the 


Fig.  84. — A  retouched  rontgenogram  of  a  case  of  spina  bifida  in  which  tibia  grafts 
(AB  and  AC)  had  been  inserted  6  months  previously  for  marked  lordosis  and  weakness. 
The  grafts  in  this  case  were  obtained  from  the  tibia  of  a  colored  child  of  5  years. 

sacrum  below.  The  upper  ends  are  bevelled,  so  that  when  these 
bevelled  surfaces  come  together  the  grafts  form  an  acute  angle, 
like  an  inverted  V.  The  grafts  are  placed  at  this  angle  in  the 
beds  prepared  for  them,  and  are  held  firmly  in  place  in  their 
bony  contacts  by  drawing  the  split  ligaments  over  them  with  in- 
terrupted sutures  of  medium  kangaroo  tendon  (see  Fig.  83). 


pott's  disease  and  other  spinal  lesions  143 

Skin  wounds  are  closed  and  the  patient  placed  on  a  fracture  bed 
for  6  weeks. 

FRACTURE  OF  THE  SPINE 

In  cases  of  fracture  of  the  spine  with  persistent  non-union, 
presenting  the  symptoms  of  pain,  disability  and  increasing  de- 


FiG.   85. — Bone  graft  inserted  into  spinous  processes  (as  for  Pott's  disease)  for  a  fracture 
of  the  spine  with  complete  relief  of  symptoms.     (Palmer.) 

formity,  the  treatment  indicated  is  mechanical  support.  This 
has  hitherto  been  attempted,  with  varying  success,  by  plaster-of- 
Paris  jackets  and  spinal  braces.     If  there  has  not  been  vertebral 


144  lU)NK-r;RAFT    SURGERY 

disj)laceiiieiit  with  decided  pressure  on  the  cord,  the  bone  graft, 
as  inserted  for  Pott's  disease,  furnishes  a  most  reUable  and  per- 
manent i'(^h(^f.  Sn<i;lit  vertebral  disphicenient  may  be  overcome 
when  placing  the  graft.  Pressure  of  any  amount  should  be 
relieved  by  laminectomy.  If  subsequently  a  kyphosis  appears 
as  a  result  of  the  laminectomy,  a  bone  graft  may  be  inserted  to 
include  the  laniinectomized  vertebrjB,  as  Avell  as  one  spinous 
process  above  and  another  below. 

The  bone  graft  is  especially  needed  in  fracture  of  the  cervical 
spine  when  a  displacement  has  been  reduced  and  there  is  danger  of 
a  relapse  of  the  displacement.  The  method  of  treatment  is  indi- 
cated in  spondylitis  traumatica  (Kiimmell's  disease)  and  neuro- 
pathic spine  (Charcot)  where,  on  account  of  rarefying  osteitis, 
crushing  of  the  vertebral  bodies  produces  increasing  deformities, 
with  possible  cord  compression;  also  in  certain  fresh  fractures. 

TUBERCULOSIS  OF  THE  SACROILIAC  JOINT 

The  prognosis  of  tuberculosis  of  the  sacroiliac  joint,  when 
treated  by  conservative  methods,  is  most  unfavorable.  Tubby 
states  that  7.9  per  cent,  only  recovered  in  the  moist  type  when 
treated  by  conservative  means,  in  a  series  of  thirty-eight  cases. 
As  in  the  case  of  bone  and  joint  tuberculosis  elsewhere,  the 
prognosis  is  more  favorable  in  children  than  in  adults.  The 
joint  is  most  unfavorable  for  external  splint  fixation,  largely  on 
account  of  its  anatomical  architecture.  Its  joint  surfaces  are 
oblique,  inclining  from  above  downward,  forward,  and  outward. 
Its  strength  is  wholly  dependent  upon  its  ligaments.  It  furnishes 
no  chance  for  leverage  control  by  external  appliances. 

The  sacrum,  on  account-  of  its  extreme  inclination,  is  at  the 
disadvantage  of  being  an  inverted  key  to  an  arch. 

Conservative  treatment  is  best  carried  out  by  the  double 
Thomas  hip  splint  or  the  double  plaster-of-Paris  spica,  in  con- 
junction with  recumbency  during  the  acute  stage. 

Internal  bone  fixation  offers  the  only  satisfactory  means  of 
immobilization,  on  account  of  the  above-mentioned  anatomical 


pott's  disease  and  othee  spinal  lesions 


145 


conformation,  together  with  the  very  powerful  muscular  action 
which  affects  this  joint. 

Author's  Operative  Technique. — The  following  technique  has 
been  devised  by  the  author  for  using  the  bone  graft  in  this  con- 
dition, and  has  furnished  most  satisfactory  results.  The  pos- 
terior-superior spine,   the  wing  of  the  ilium  and  first  spinous 


Fig.  86. — Diagram  from  the  rontgenogram  of  an  actual  case  of  tuberculosis  of  the 
last  lumbar  vertebrse  and  the  right  sacro-iliac  joint.  The  spinal  graft  was  inserted  by 
the  author's  regular  technique  for  Pott's  disease.  The  graft  controlling  the  sacroiliac 
joint  was  joined  by  a  carpenter's  half  mortise  to  the  spinal  graft  (see  small  upper  right- 
hand  drawing.)  The  callus  uniting  the  two  grafts  is  indicated.  The  graft  was  joined 
to  the  posterior  wing  of  the  ilium  by  shaping  it  into  a  wedge  end  which  was  forced  into  a 
split  in  the  ilium  made  by  an  osteotome. 

process  of  the  sacrum  are  reached  by  a  curved  incision.  The 
posterior  border  of  the  wing  of  the  ilium  and  the  spinous  process 
are  split,  with  their  attached  ligaments,  by  a  thin  osteotome, 
forming  a  gutter  to  receive  the  ends  of  the  graft.  A  cleft  is 
made  in  the  posterior  wing  of  the  ilium  by  driving  a  broad  and 
thin  osteotome  into  it  just  anterior  to  its  superior  edge  (see  illus- 
tration) and  in  a  direction  laterally  from  within  outward.     The 

10 


UCd 


BONE-GRAFT    SURGERA" 


j^raft,  which  is  hit  or  secured,  is  formed  with  a  wedge  end  to  be 
driven  into  this  cleft. 

If  practicable,  a  surface  of  the  sacrum  is  denuded  to  furnish 
additional  contact  with  the  graft.  The  wound  is  packed  wdth  a 
saline  compress  and,  with  the  patient  still  in  the  prone  position, 


Fig.   87. — Rontgenogram  of  case  of  tuberculosis  of  last  luniljar  vertebra  and  sacro- 
iliac joint  of  which  Fig.  86  is  a  drawing. 

AB  is  spinal  graft;  CD  is  graft  for  fixation  of  sacroiliac  joint. 


the  leg  is  flexed  and  a  graft  of  sufficient  length  removed  from  the 
crest  of  the  tibia  by  the  motor  saw,  as  described  in  the  use  of  the, 
bone  graft  in  Pott's  disease,  except  for  the  just-mentioned  wedge 
end.  The  width  of  the  graft  should  be  three  times  the  thickness 
of  the  cortex.     The  thickness  should  include  the  w^hole  cortex, 


pott's  disease  and  other  spinal  lesions  147 

periosteum,  endosteum,  and  a  small  amount  of  the  adhering 
marrow.  The  graft  is  placed  in  its  prepared  bed,  and  the 
ligaments  are  drawn  over  it  by  interrupted  sutures  of  medium 
kangaroo  tendon  (see  Fig.  86).  The  skin  wound  is  closed,  and 
the  patient  placed  on  the  back  on  a  fracture  bed  for  a  period 
of  not  less  than  5  weeks.  There  should  be  no  necessity  for  fur- 
ther mechanical  treatment. 

DISLOCATION  OR  RELAXATION  OF  THE  SACROILIAC  JOINT 

Dislocation  of  this  joint  is  a  most  rare  condition,  but  if  met 
with,  reduction  under  general  anaesthesia  should  be  resorted  to. 
This  is  best  accomplished  by  hyperextending  the  spine,  making 
traction  upon  the  leg  of  the  affected  side,  and  by  manipulation 
of  the  ilium  into  a  proper  relation  with  the  rest  of  the  pelvis. 
Post-operative  dressings  should  consist  of  a  well-moulded 
plaster-of-Paris  spica  extending  from  the  axilla  to  the  knee,  with 
the  lumbar  spine  in  hyperextension.  The  spica  should  be  worn 
for  10  to  12  weeks.  In  relapsing  cases,  the  bone  graft  as  applied 
for  the  treatment  of  tuberculous  sacroiliac- joint  disease  is  a  per- 
manent and  reliable  means  for  relieving  this  condition. 

The  joint  may  suffer  a  relaxation  from  a  sudden  trauma, 
difficult  labor,  or  a  long-continued  strain  in  an  awkward  or 
stooping  posture.  The  symptoms  are  pain  over  the  involved 
joint  and  total  lateral  deviation  of  the  spine  to  the  side  opposite 
the  involved  joint.  Pain  is  elicited  upon  assuming  any  attitude 
which  brings  strain  upon  the  articulation,  such  as  going  up  or 
down  stairs,  sitting  with  the  normal  lumbar  curve  obliterated, 
lying  in  bed  flat  upon  the  back  and  turning  in  bed  which  is  a 
most  constant  symptom. 

Upon  palpation  physical  examination  reveals  pain  at 
the  affected  joint  and  muscular  rigidity  of  the  lumbar  spine. 
With  the  patient  upon  his  back,  motion  at  the  hip  is  normal  and 
free  with  the  leg  flexed  upon  the  thigh.  Flexion  of  the  thigh 
with  the  leg  extended  produces  pain  in  the  involved  sacroiliac 
joint  of  that  side  (Goldthwait  symptom).  In  severe  cases 
pain  is  even  produced  on  the  opposite  side  by  flexing  the  thigh 


148  BONE-GRAFT   SURGERY 

ill  this  way.      Pain  is  elicited  by  pressing  the  wings  of  the  ilia 
together. 

The  usual  conservative  treatment,  consisting  of  belts  or 
corsets  with  sacral  pads  is,  as  a  rule,  satisfactory.  Occasionally, 
however,  in  severe  long-standing  cases,  conservative  treatment  is 
insufficient,  and  it  becomes  necessary  to  resort  to  bone-graft 
fixation.  The  technique  in  such  cases  is  precisely  the  same  as 
described  elsewhere  in  this  volume  for  the  treatment  of  tubercu- 
lous osteitis  of  this  joint. 


CHAPTER  IV 

THE  INLAY  BONE  GRAFT  IN  THE  OPERATIVE  TREATMENT 

OF  FRACTURES 

Author's  Technique. — In  no  other  field  of  surgical  practice 
is  there  a  greater  difference  of  opinion  than  that  existing  in 
reference  to  the  open  or  operative  treatment  of  fractures,  as  con- 
trasted with  the  conservative  or  non-operative  treatment.  The 
important  question  arises :  In  which  case  is  operative  treatment 
demanded,  and  in  which  will  non-operative  treatment  give  a 
perfectly  satisfactory  result? 

It  is  exceedingly  difficult  to  answer  this  question  with  any 
approach  to  accuracy  from  clinical  evidence  alone.  The  cir- 
cumstances of  clinical  observation  have  such  a  wide  range  that 
comparison  of  the  results  of  different  methods  of  treatment  is 
almost  impossible.  Some  of  the  more  important  of  these  vary- 
ing factors  are:  The  age  and  health  of  the  patient;  the  site  and 
anatomical  condition  of  the  fracture;  the  length  of  time  that  has 
elapsed  before  treatment  was  undertaken;  the  period  between 
the  termination  of  the  treatment  and  the  recording  of  the  result; 
the  skill  and  attitude  of  mind  of  the  surgeon;  and  the  method 
employed.  "  It  is  only  by  experiment  that  these  variables  can  be 
replaced  by  constants  and  a  true  estimate  made  of  the  factors 
which  underlie  success  or  failure  of  operative  methods" (Groves). 

Lane  operates  on  all  cases  of  simple  fracture  of  the  long 
bones  in  which  he  is  unable  to  obtain  accurate  apposition  of 
fragments,  when  the  restoration  of  the  bone  to  its  normal  form 
is  of  mechanical  importance  to  the  patient.  With  the  develop- 
ment and  perfection  of  aseptic  surgical  technique,  there  has 
been  a  natural  coincident  increase  in  the  number  of  simple 
fresh  fractures  submitted  to  operation.  Many  surgeons  are 
feeling  at  present  that  the  numerous  badly  set  fractures  which 

149 


150  BONE-GRAFT    SURGERY 

become  useful  only  after  1  year  to  18  months  might  liave 
better  functional  results  in  a  much  shorter  period. 

Whatever  methods  are  adopted  should  be  efficient  from  the 
start.  ''If  a  surgeon  is  doubtful  whether  he  can  treat  a  frac- 
ture efficiently  by  non-operative  means,  he  ought  to  consider 
whether  he  cannot  do  better  by  operating  at  once.  He  ought 
not  to  say:  'Well,  we  can  see  what  becomes  of  it,  and  if  it  is 
not  satisfactory  we  can  operate  later,'  for  by  so  doing  the  only 
opportunity  of  getting  a  good  functional  result  may  be  irretriev- 
ably lost"  (Jones). 

Fortunately  the  day  is  fast  disappearing  when  fracture  cases 
in  our  large  hospitals  are  passed  over  for  treatment  to  internes  or 
to  some  disinterested  junior  attending.  The  advent  of  the  X-ray 
has  helped  to  awaken  the  profession  to  a  recognition  of  the  fact 
that  in  fractures  we  have  some  of  the  most  difficult  and  interest- 
ing problems  to  be  met  with  in  the  whole  realm  of  surgery,  and 
that  there  is  nothing  that  taxes  the  experience,  anatomical 
knowledge,  and  good  judgment  of  a  surgeon  to  a  greater  degree 
than  a  difficult  fracture. 

During  the  last  few  years,  as  the  profession  has  been  more 
carefully  investigating  the  end  results  after  fractures,  a  strong 
feeling  has  developed  that  the  results  must  be  improved.  Both 
the  profession  and  the  public,  since  the  advent  of  the  X-ray, 
have  become  educated  to  higher  ideals  and  are  demanding 
shorter  and  more  efficient  treatment,  a  shorter  period  of  dis- 
ability and  better  functional  results. 

A  plea,  how^ever,  should  be  made  for  caution  against  the 
too  enthusiastic  adoption  of  the  open  method  of  treatment  as  a 
routine  means  of  dealing  with  simple  fractures.  Hitzrot  has 
well  stated  that:  "The  most  striking  contra-indications  to  an 
open  operation  upon  a  broken  bone  are  inexperience  on  the  part 
of  the  surgeon,  unsuitable  surroundings,  and  insufficient  equip- 
ment. Furthermore,  the  operator  should  have  a  thorough 
knowledge  of  the  anatomy  of  the  region  to  be  operated  upon  and 
should  understand  the  physical  function,  i.e.,  the  physics  of  the 
muscles,  ligaments,  etc.,  involved  in  the  injury.     Such  knowl- 


INLAY   BONE    GRAFT    IN    FRACTURES 


151 


Figs.  88  and  89. — A  is  a  rontgenogram  of  an  ununited  fracture  of  the  tibia  of  8 
months'  duration.  Two  Lane's  plates  were  put  on  immediately  after  the  fracture  oc- 
curred and  primary  union  of  soft  tissues  and  excellent  apposition  of  the  fragments  were 
obtained  as  X-ray  shows.  Nevertheless,  union  did  not  occur,  as  has  been  observed  in 
many  other  similarly  plated  cases.  The  metal  plates  were  removed  and  an  inlay  graft 
(AB)  dVi  in.  long  slid  down  from  the  upper  fragment  as  shown  in  rontgenogram  Fig  89. 
The  arrow  (c)  indicates  region  between  the  fragment  ends  where  a  large  number  of  small 
grafts  were  inserted.  The  screws  were  found  disengaged  from  the  bone  and  laying  in 
large  cavities  in  the  bones.  There  was  a  large  amount  of  bone  destruction  about  the 
plates  and  screws.  There  was  no  callus  formation  whatsoever  in  the  region  of  the 
metal.  Bony  union  occurred  almost  immediately  after  the  inlay  graft.  In  5  weeks' 
time  the  union  was  very  firm  and  the  limb  is  functionating  normally,  now  9  months 
after  the  graft  operation.  It  is  believed  that  in  this  case  as  well  as  manj'  others  that 
the  metal  plates  contributed  to  non-union. 


152 


BONE-GRAFT    SURGERY 


edge  may  prevent  some  of  the  glaring  faults  already  existent  in 
the  treatment  of  broken  bones." 

It  should  be  emphasized  that  while  operative  treatment  is 
necessary  in  many  cases,  there  are  plenty  of  instances  of  closed 
fracture  in  which  it  is  not  needed.     Excellent  results  can  often 


Fig.  90. — Fracture  of  syphilitic  femur,  4  months  after  operation;  phite  behind 
left  femur.  The  swelling  on  the  opposite  side  of  femur  from  the  metal  plate  is  callus. 
Note  that  there  is  no  callus  in  region  of  the  plate.  (Rutherford  Morison  in  British 
Journal  of  Surgery.) 


be  secured,  both  as  to  anatomical  restoration  and  function,  by 
non-operative  treatment  by  a  careful,  experienced  surgeon  who 
has  a  mechanical  mind,  anatomical  knowledge,  and  experience 
in  the  management  of  plaster  of  Paris  and  the  various  fixation 
splints. 

The  strong  objections  to  the  operative  treatment  by  using 


INLAY   BONE    GRAFT    IN    FRACTURES 


153 


internal  metal  plate  (Lane)  are  the  danger  of  infection  and 
delayed  or  non-union.  Both  of  these  objections,  especiallj^  the 
latter — and  to  a  very  large  degree  the  former — can  be  over- 
come by  the  use  of  the  inlay  bone  graft  instead  of  the  metal 


Fig.  91. — Six  months  after  insertion  of  graft.  Note  destruction  of  upper  end  of 
graft  from  contact  with  metal  plate  and  screws,  with  resulting  non-union.  (Morison, 
British  Journal  of  Surgery.) 

plate.  Dr.  J.  B.  Roberts,  in  the  Annals  of  Surgery,  of  April, 
1913,  emphasized  the  inhibitory  influence  of  the  Lane  plate 
upon  union  by  quoting  Martin,  who  states:  "It  is  noteworthy 
that  union  is  usually  delayed,  that  the  time  of  treatment  is  not 


154  BONE-GKAFT   SURGERY 

materially  shortened,  that  the  results  are  not  uniformly  good; 
but  taken  as  a  whole,  they  are  infinitely  better  than  could  possi- 
bly have  been  secured  by  other  than  operative  means.  There 
has  seemed  to  l)e  a  relation  between  the  size  of  the  internal 
(metal)  splint  and  the  promptness  of  final  union.  In  other 
words,  we  have  felt  that  the  less  foreign  matter  we  have  put 
into  the  wound  the  quicker  it  got  well." 

In  a  recent  paper,  W.  P.  Carr  states:  ''I  have  never  put  on 
a  Lane  plate,  but  I  have  had  to  remove  many.  Of  54  that 
were  applied  by  half  a  dozen  of  our  best  surgeons  at  the-  Emer- 
gency Hospital,  30  had  to  be  removed  for  non-union,  suppura- 
tion, irritation,  breaking  or  bending  of  the  plate.  The  other 
24  may  have  trouble  later." 

Blake  has  well  said:  ''I  have  always  believed  that  the  less 
non-absorbable  foreign  material  used  the  better,  and  my  next 
preference  to  nothing  is  chromicized  gut;  and  I  prefer  a  single 
screw  to  a  plate  and  eight  screws.  Even  as  the  indications  for 
operation  vary,  so  do  those  for  the  method  of  internal  fixation. 
The  amount  of  internal  fixation  depends  upon  whether  it  is  only 
necessary  to  steady  the  fragments  until  the  external  fixation  is 
applied,  or  whether  it  is  to  be  subjected  to  violent  strains  as  may 
happen,  for  instance,  in  some  fractures  of  the  femur.  It  has 
been  amply  proven  by  experimental  and  clinical  evidence  that 
a  constant  strain  will  loosen  the  strongest  form  of  internal  fixa- 
tion. Just  as  a  suture  drawn  too  tight  will  produce  absorption 
and  cut  the  soft  parts,  so  will  a  constant  strain  draw  the  screws 
of  a  plate,  no  matter  how  well  introduced.  The  point  I  wish  to 
make  is  that  we  have  to  rely  chiefly  upon  external  dressings ;  the 
function  of  the  internal  fixation  being  to  obviate  motions  or 
displacements  which  may  be  caused  by  muscular  action,  or  by 
sudden  strain,  such  as  may  happen  during  the  application  or 
change  of  external  splints  or  dressings.  One  of  the  chief  ad- 
vantages of  internal  fixation  is  the  possibility  of  early  and  fre- 
quent passive  motion  of  neighboring  joints  without  endangering 
union." 

Martin  states   {Surgery,  Gynoecology  and  Ohstetrics,  August, 


INLAY  BONE  GRAFT  IN  FRACTURES  155 

1906) :  ''Metal  plates,  screws,  or  wires  are  open  to  the  objection 
that,  even  though  the  wound  heals  primarily  over  them,  they 
remain  always  a  potential  cause  of  localizing  infection.  There 
are  probably  few  surgeons,  who  because  of  discharging  sinuses, 
have  not  been  compelled  to  remove  such  foreign  bodies  from 
patients  who  had  been  reported  by  their  colleagues  as  per- 
manently healed.  The  liability  of  both  early  and  late  suppura- 
tion is  in  direct  proportion  to  the  size  of  the  foreign  body 
employed." 

Groves  reports  that  in  all  his  experiments  (2  cats'  tibiae; 
2  rabbits'  tibiae;  5  rabbits'  femora)  where  metal  plates  were  used 
to  hold  fractures,  "the  bone  ends  became  disunited  within  the 
first  week,  with  more  or  less  angulation  and  deformity.  This  was 
due  in  every  case  to  the  screws  coming  out.  Usually  both 
screws  came  out  from  one  fragment  and  the  plate  remained  fixed 
to  the  other;  but  sometimes  all  the  screws  w^ere  out  and  the  plate 
was  loose  among  the  muscles.  Examination  of  the  bone  from 
these  cases  showed  that  the  screw  holes  became  enlarged,  so  that 
whereas  the  screws  held  tightly  at  the  time  they  were  inserted, 
later  the  same  sized  screw  would  drop  loosely  out  of  the  hole." 
The  screws  quickly  gave  way  from  bone  absorption  around  them. 
''A  second  undesirable  feature  of  these  series  of  experiments  was 
the  tendency  to  sepsis,  with  occasional  extrusion  of  the  plate. 
''That  it  was  not  due  to  faulty  technique  is  shown  by  the  fact 
that  in  other  methods  (no  metal  used)  where  the  same  procedure 
was  observed,  there  was  very  little  sepsis.  This  marked  tend- 
ency to  sepsis  as  compared  with  other  methods,  is  due  to  the 
combination  of  a  great  irritation,  caused  by  free  movement  of 
the  displaced  fragments  on  account  of  loosened  screws,  with  the 
presence  of  a  foreign  body.  Groves  believes  that  "many  times 
the  sepsis  is  the  result  and  not  the  cause  of  the  loosening  of  the 
screws,"  and  it  is  evident  from  his  series  of  experiments  that 
the  screws  do  rapidly  become  loose  in  all  cases. 

The  presence  of  a  metal  plate,  instead  of  stimulating  osteo- 
genesis, retards  it.  This  is  in  strong  contrast  to  the  bone  graft, 
which  not  only  produces  bone  itself  but  also  stimulates  the  bone 


156 


BONE-GKAFT    .SUKUEKV 


ends  to  more  active  osteooeiiesis.  There  is  an  immediate  adhe- 
sion of  the  inlay  graft  to  the  gutter  walls  of  the  fragments, 
and  as  times  elapses  this  becomes  a  firmer  and  firmer  bone  union. 
Furthermore,  the  graft  has  certain  bacteria-resisting  and  bac- 
tericidal properties. 


Fig.  92. — Roiitgeiiograiii  of  couiinimUiMl  oljliciiu;  fr;iclurc  ol'  femur  in  :i  wuiiiau 
68  years  of  age,  3  months  after  operation,  in  which  a  screw,  two  wires  and  a  plate 
were  used.     (Blake.) 

Hitzrot  enumerates  the  following  indications  for  operative 
treatment : 

''Fracture  of  the  patella,  with  separation  of  the  fragments. 
"Fracture  of  the  olecranon,  with  separation  of  the  fragments. 
"Fracture   of   the   head   of   the   radius,   with   displacement 


Fig.  93. — Rontgenograin  of  same  fracture  as  shown  in  Fig.  92.  The  screws  have 
come  out  and  plate  has  become  partly  displaced  into  the  soft  tissues.  One  of  the  wires 
has  produced  absorption  and  a  spontaneous  refracture  at  A.      (Blake.) 

of  the  fragments,  or  where  the  fracture  line  involves  the  radio- 
ulnar   joint. 

"Fracture  of  the  shaft  of  a  long  bone  in  which  the  soft  parts 
become  interposed  between  the  fractured  ends   of  the  bone. 

"Fracture  of  the  carpal  and  tarsal  bones,  with  w4de  separa- 


INLAY   BONE    GRAFT    IN    FRACTURES  157 

tion  of  the  fragments  or  displacement  of  the  fragments  (carpal 
scaphoid   and   the   astragalus). 

''Fracture  dislocation,  viz.,  fracture  of  the  surgical  neck  of 
the  humerus  with  dislocation  of  the  head. 

"Fractures  of  the  tuberosities  and  condyles  of  the  various 
bones,  with  rotation  of  the  fractured  process,  for  example,  frac- 
ture of  the  external  condyle  of  the  humerus  with  rotation  of 


Fig.  94. — This  case  illustrates  how  treacherous  foreign  substances  are  when  left 
imbedded  in  the  tissues.  The  loop  of  silver  wire  shown  in  this  rontgenogram  was 
employed  to  fix  an  epiphyseal  fracture.  The  wound  healed  by  primary  union  and  the 
convalescence  was  uneventful.  Four  years  later  a  large  abscess  appeared  about  the 
wire,  necessitating  removal  of  wire  and  drainage  of  abscess. 

the  condyle,  so  that  the  fractured  surface  points  outward  or 
away  from  the  line  of  fracture  in  the  shaft. 

"Furthermore,  operation  is  indicated  when  there  is  haemor- 
rhage due  to  the  injury  of  a  large  vessel;  when  there  are  signs  of 
compression  of  a  nerve;  when  the  sharp  point  of  a  fragment  is 
caught  in  the  skin;  and  when  infection  has  occurred  in  the  region 
of    the   fracture." 


158  'J^     BONE-CRAFT    SURGERY 

Practically  every  type  of  fracture  may  need  operation  if 
reduction  is  otherwise  unfeasible.  Necessity  for  open  operation 
should  be  recognized  within  the  first  2  weeks  after  the  injury. 
The   X-ray   obviates   any   difficulty   in   deterniiniiij;-   this   fact. 

Those  fractures  which  need  operation  the  most  frequently 
are  fractures  of  all  long  bones — especially  the  femur;  lower 
third  of  tibia;  fractures  involving  joints,  as  fractures  of  the  neck 
of  the  femur,  lower  end  of  humerus,  and  femur;  and  fractures  of 
the  forearm. 

In  February,  1911,  the  council  of  the  British  Medical 
Association  appointed  a  committee  "to  report  on  the  ultimate 


Fig.  95. — Skiagram  of  rabbit's  tibia,  21  days  after  plating.  Screws  have  come 
out  of  the  lower  fragment,  and  the  plate  protruded  from  the  wound.  (Groves,  in 
British  Journal  of  Surgery.) 

results  obtained  in  the  treatment  of  simple  fractures,  with  and 
without  operation,"  and  the  following  conclusions  were  arrived 
at  by  the  committee: 

"1.  It  is  possible  by  either  non-operative  or  operative  treat- 
ment to  obtain  a  high  percentage  of  good  results  in  children. 
The  results  of  non-operative  treatment  in  children,  with  the 
exception  of  both  bones  of  the  forearm,  are  unlikely  to  be  im- 
proved upon  by  any  other  method.  Operative  results  expressed 
in  percentage  are  approximately  the  same  as  the  non-operative: 
1,017  non-operative  cases,  90.5  per  cent,  good  functional  re- 
sults; 64  operative  cases,  93.6  per  cent,  good  functional  results. 


INLAY   BONE    GRAFT    IN    FRACTURES 


159 


"2.  In  comparison  with  the  results  in  children,   the  non- 
operative  results  in  those  past  15  are  not  satisfactory^,  and  from 


Fig.  96.  Fig.  97.  Fig.  98. 

Fig.  96. — Skiagram  of  rabbit's  femur  (No  .26),  21  days  after  plating.  Screws  have 
come  out  from  lower  end.      Mal-uuion.      (Groves,  in  British  Journal  of  Surgery.) 

Fig.  97. — Rabbit's  femur  (No.  26),  21  days  after  plating.  Screws  have  come  out 
from  the  lower  fragment.  Mal-union  with  lateral  displacement.  (Groves,  in  British 
Journal  of  Surgery.) 

Fig.  98. — Rabbit's  femur  (No.  28),  31  days  after  plating.  The  screws  have  come 
out  from  the  upper  fragment.  Note  the  quantity  and  density  of  the  callus.  (Groves, 
in  British  Journal  of  Surgery.) 


the  analysis  of  the  age  groups  it  is  clear  that  there  is  a  pro- 
gressive depreciation  in  the  functional  result  as  the  age  advances 


IGO 


BONE-GRAFT    SURGERY 


in  those  cases  submitted  to  non-operative  treatment — i.e.,  the 
older  the  patient,  the  worse  the  result. 

'^3.  Although  the  functional  result  may  be  good  with  an  in- 


FiG.  yy. — The  author  is  indebted  to  Dr.  Lathrop  of  Ilazk-luu,  Peiuui.,  for  the 
privilege  of  reporting  this  case,  which  was  a  fresh  comminuted  fracture  of  the  tibia 
and  fibula.  A  sliding  inlay  graft  from  upper  fragment  held  the  fragments  perfectly 
(author's  technique).  The  rontgenograms  show  position  of  fragments  before  and 
after  operation.      The  result  was  excellent. 

different  anatomic  one,  the  most  certain  way  to  obtain  a  good 
functional  result  is  to  secure  a  good  anatomic  one.  Of  the 
operative  methods,  those  which  secure  perfect  reposition  and 
absolute  fixation  of  the  fragments  yield  better  results  than  meth- 


INLAY   BONE    GRAFT    IN    FRACTURES  161 

ods  which  fall  short  of  this ,  and  imperfect  fixation  of  the  frag- 
ments by  wire  or  other  suture  has  been  found  unsatisfactory  in 
fractures  of  the  long  bones  (the  olecranon  excepted). 

"4:.  In  order  to  secure  the  most  satisfactory  results  from 


Fig.  100. — A  fresh  three-fragment  fracture  of  the  humerus  inserted  to  illustrate 
a  new  point  of  view  in  operative  management  of  this  case  and  others  of  similar  nature. 
The  small  third  fragment  in  this  case,  which  had  been  pulled  downward  by  the  brachialis 
muscle,  was  in  the  way  of  fixing  the  long  fragments,  therefore  it  was  removed  and 
placed  in  saline.  This  facilitated  the  operation  and  gave  free  access  to  the  long  frag- 
ment, the  tips  of  which  were  fixed  together  with  heavy  kangaroo  tendon.  The  third 
fragment  was  then  taken  from  the  saline  solution  and  placed  in  position.  It  was 
fixed  firmly  with  kangaroo  tendon  and  furnished  a  very  efficient  bone-graft  internal 
splint. 

11 


162 


BONE-GKAFT    SURGERY 


/ 


YxG  101. — Pseudarthrosis  of  the  tibia  united  by  the  inlay  bone  graft  CB.  Firm 
union  3  months  after  the  operation,  notwithstanding  that  there  has  been  no  callus 
between  the  fragments  at  A. 


INLAY   BONE    GEAFT    IN    FRACTURES 


163 


operative  treatment,  it  should  be  resorted  to  as  soon  as  practi- 
cable. Operative  treatment  should  not  be  regarded  as  a  method 
to  be  employed  when  non-operative  measures  have  failed,  as 
the  results  of  secondary  operations  compare  very  unfavorably 
with  those  of  immediate  operations. 


4  V 


Fig.   102.  Fig.   103. 

Fig.  102. — Ununited  fracture  of  tibia  of  1  year's  duration  after  3  months  of  Bier 
hypersemia  and  repeated  blood  injections  between  fragments.  An  inlay  graft  was 
inserted  from  the  other  tibia  with  immediate  union.  This  was  one  of  the  author's 
first  cases  and  was  operated  in  Dec,  1911. 

Fig.  103. — Same  case  as  Fig.  102.  The  inlay  graft  AB  is  too  short,  but  on 
account  of  its  accurate  fit  the  union  was  immediate. 


"5.  Operative  treatment  of  fractures  requires  special  skill 
and  experience. 

"6.  A  considerable  portion  of  the  failures  is  due  to  infection. 
"7.  The  mortality  due  to  operative  treatment  is  so  small 


164 


BONE-GRAFT   SURGERY 


that  it  cannot  be  urged  as  a  sufficient  reason  against  this  method 
of  treatment"  (Hitzrot). 

8.  In  nearly  all  age  groups,  operative  cases  show  a  higher 
percentage  of  good  results  than  non-operative  cases. 

The  author  has  used  the  inlay  graft  in  the  treatment  of 


Fig.  104.  Fig.   105. 

Fig.  104. — Preparing  gutter  for  inlay  tibial  graft  in  a  fracture  at  the  surgical  neck 
of  the  humerus. 

Fig.  105. — Strips  of  bone  are  removed,  forming  a  cortical  gutter  in  lower  fragment 
and  lower  part  of  upper  fragment.  A  tunnel  under  the  projecting  humeral  head  is  being 
prepared  so  as  to  lengthen  gutter  and  get  a  longer  contact  of  graft  to  upper  fragment. 

fractures  since  1911,  and  has  secured  union  in  every  instance  in 
a  series  of  50  cases  of  fresh  and  ununited  fractures.  Many  of 
the  ununited  fractures  were  of  the  most  desperate  character. 
One  of  the  series  had  been  operated  upon  seven  times,  including 
intramedullary  grafting.  In  three  of  the  series,  the  intramed- 
ullary graft  had  been  unsuccessfully  employed;  two  had  been 


INLAY   BONE    GRAFT    IN    FRACTURES 


165 


operated  upon  unsuccessfully  three  times ;  and  three  of  the  cases, 
twice.  Twenty-seven  of  these  cases  were  previously  plated  with 
Lane's  plates. 

In  reference  to  these  statistics  the  author  wishes  to  advance 
a  further  statement.  A  metal  plate  placed  on  a  fracture  in- 
hibits seriously,  as  a  rule,  the  formation  of  callus  on  that  area 
of  the  fragments  at  the  same  time  that  osteogenesis  may  be 


TIBIALGRAFT 


Fig.    106. — Inlay  graft  fixed  in  place  with  kangaroo  tendon. 


active  on  the  other  areas  of  the  fragments,  and  in  a  certain 
percentage  of  cases  the  inhibition  to  callus  formation  is  sufficient 
to  result  in  non-union,  even  though  there  may  have  been  no 
infection.  There  are  few  surgeons  who  execute  Lane's  tech- 
nique, therefore  infection  occurs  in  a  varying  percentage  of 
cases,  which  is  a  frequent  cause  of  non-union.  Apropos  of  this, 
Thomas  has  emphasized  the  unreliability  of  the  Lane  plate  as 
used  by  a  number  of  operators,  and  cites  statistics  of  450  fracture 


166 


BONE-GRAFT   SURGERY 


eases  gathered  by  him  at  the  Cook  County  Hospital.  It  was 
found  that  it  had  been  necessary  to  remove  the  Lane  plates, 
on  account  of  suppuration  or  other  causes,  in  48  per  cent,  of  the 
cases  which  had  been  plated. 

Wlien  the  author  first  began  (1911)  to  employ  the  inlay  bone 
graft  in  the  treatment  of  fractures  and  other  bone  conditions, 
hand  tools  were  used.  After  doing  about  50  of  these  opera- 
tions and  thoroughly  realizing  the  inadequacy  of  all  hand  tools. 


Fig.  107. — Bone-graft  inlay  method  for  treating  fresh  and  ununited  fractures.  (A) 
Proximal  fragment.  (5)  Distal  fragment.  (C)  Graft  sawed  from  proximal  fragment 
and  slid  half  across  point  of  fracture.  The  inlay  should  always  be  inserted  when  possible 
on  the  side  of  an  oblique  fracture  as  indicated  in  this  drawing.  Over-riding  of  fragments 
and  shortening  of  the  limb  are  then  prevented  by  virtue  of  the  mechanical  property  of 
the  inlay.  (D)  Portion  of  bone  removed  from  distal  fragment  by  motor  twin  saw  in 
forming  gutter  for  graft  C.  Dotted  lines  represent  division  of  this  fragment  for  making 
dowel  pegs  to  be  inserted  at  (jg,  at  the  point  e.  (e)  Indicates  location  of  drill  holes  for 
reception  of  dowel  pegs  to  hold  graft  in  position.  These  holes  are  made  with  a  motor 
drill  which  is  the  counterpart  in  size  to  the  dowel  cutter  used  in  making  the  pegs. 
Therefore  the  fit  must  be  accurate.  (F)  Gap  remaining  in  shaft  following  the  sliding 
distally  of  graft  C.  (^)  Cuts  at  end  of  gutter  made  by  small  motor  saw  in  freeing  the 
bone  from  the  gutter,  (j)  The  converging  drill  holes  at  the  side  of  the  gutter  showing 
kangaroo  tendon  passed  through  and  tied  in  position  securing  graft  C,  that  is,  if  tendon 
is  chosen  as  the  fixation  agent. 


he  turned  to  the  development  of  motor-driven  tools,  and  about 
2|  years  ago  he  began  to  perfect  the  motor  mill  which 
he  is  now  using  with  so  much  satisfaction.  It  is  almost  like 
a  cabinet-maker's  or  carpenter's  mill.  With  it  the  surgeon 
can  saw  bone,  drill  it,  turn  it  into  nails  (with  attached  lathe), 
or  mould  it  into  any  shape  or  form  required  with  accuracy  and 
speed,  so  that  he  can  devote  himself  to  the  fixation-ligature 
work  and  delicate  tissue  work  that  is  necessary  with  the  least 


INLAY   BONE    GRAFT    IN    FRACTURES 


167 


amount  of  time  and  trauma.  All  the  heavy  and  laborious  bone 
work  is  done  by  electrical  power.  The  surgeon  can  also  do 
many  things  with  motor-driven  tools  which  it  would  be  impos- 
sible to  do  with  hand  tools. 

The  twin  saws  cut  bone  into  inlays  or  make  grooves  for  the 
same  of  exactly  uniform  width  throughout,  thus  assuring  a 
''cabinet-maker's  fit,"  which  in  ununited  fracture  work  is  ab- 
solutely essential  to  success  in  many  in- 
stances. In  this  respect  the  callus  may  be 
compared  to  the  glue  of  the  cabinet-maker, 
and  the  graft  to  the  accurately  fitted  w^ood 
of  the  glued  furniture.  It  is  essential  that 
the  wood  be  accurately  fitted,  otherwise  the 
glue  would  not  hold.  This  is  a  fair  compari- 
son in  many  respects,  especially  in  the  case 
of  pseudarthrosis  where  the  callus  is  meagre 
in  amount  on  account  of  the  sclerosis  of  the 
fragment  ends.  An  accurate  fit  may  mean 
success  and  an  inaccurate  fit,  failure. 

In  cases  of  fresh  fracture,  the  bone  being 
normal,  the  material  can  be  taken  from  the 
fragments  themselves  and  used  as  bone 
grafts.  This,  as  well  as  other  similar  in- 
lay technique,  would  be  difficult  without  the  use  of  the  cir- 
cular saw.  The  motor  saw  has  opened  up  a  field  of  osteoplasty 
and  of  application  of  the  bone  graft  in  various  forms  that  it  has 
been  impossible  to  develop  heretofore. 

In  place  of  wire,  the  author  always  uses  kangaroo  tendon. 
During  the  last  2  years,  he  has  not  used  metal  for  any  internal- 
fixation  purpose.  Metal  has  a  destructive  influence  upon  bone, 
and  frequently  adds  an  inhibiting  effect  which  may  be  sufficient 
to  prevent  the  fractured  bone  from  uniting.  An  osteoporosis 
or  necrosis  usually  develops  around  the  metal  screws  or  nails, 
causing  them  to  loosen  and  drop  out  in  a  very  short  time.  Then, 
too,  metal  favors  infection,  absorption,  and  disintegration  of 
tissues.     Instead  of  Lane's  plates  or  other  metal  plates,   the 


Fig.  lOS.— Illustrates 
using  two  strands  of 
kangaroo  tendon,  one  to 
prevent  graft  from  com- 
ing out  and  the  other  to 
prevent  the  graft  dis- 
placing into  the  marrow 
cavity  in  fresh  fractures 
of  large  bones  when  it 
(medullary  cavity)  is  not 
filled  with  new-formed 
bone. 


168 


BONE-GHAFT    SURGERY 


author  uses  the  inlay  g,i"d(t  for  all  cases  of  fracture  of  the  long 
bones.  For  balancing  up  deformities  of  the  limbs,  especially 
of  the  feet,  the  author  has  used  bone-graft  wedges,  taken  mostly 

from  the  til)ia  or  opposite  side  of  the 
foot.  In  ununited  fractures,  it  is 
xei-y  important  that  the  graft  be  long 
enough  to  have  ample  contact  with 
active  bone  beyond  the  sclerosed  or 
infected  area.  Through  the  influ- 
ence of  Wolff's  law,  a  tibia  whose 
diameter  has  been  lessened  by  ob- 
taining a  bone  graft  from  it  will  re- 
turn to  its  normal  size  and  strength 
in  about  2  or  3  months;  at  the  same 
time,  the  graft  will  likewise  prolifer- 
ate and  become  of  a  size  and  strength 
commensurate  with  the  mechanical 
requirements  of  its  new  environment. 
In  other  words,  it  is  a  physiological 
hypertrophy. 

In  every  case  of  non-union  which 
has  existed  for  any  length  of  time, 
from  any  cause  whatsoever — whether 
from  soft  tissue  between  the  frag- 
ments, local  infection,  systemic  dis- 
ease, idiosyncrasy  in  lack  of  osteogen- 
esis, or  from  any  inhibitory  influence 
to  bone  growth  from  a  Lane's  plate 

D    is     screw    hole    of    a    previous 

Lane's  plate.      The  union  from  the     Or    othcr    metal    appliaUCC there    IS 

inlay  is  firm  at  the  time  this  X-ray        ■,  tj_'x         xii-ii 

was  made  the  patient  is  walking   always  a  distmct  pathological  chauge 

on  the  limb  Nevertheless,  there  ^^  ^^le  fragment  euds,  COUSistiug  in 
IS  no  callus  at  the  ends  of  the  frag-  °  '  '^ 

ments.  diminution  and  degeneration  of  bone- 

cells  and  a  coincident  increase  of  calcium  salts,  or,  in  other  words, 
a  sclerosis.  (See  Fig.  110.)  This  eburnated  area  may  extend  as 
much  as  IM  in.  into  each  fragment,  and  osteogenesis  is  greatly 
impaired,  so  much  so  that  bone  fragments  ideally  contacted 


Fig.  109. — Ununited  fracture  of 
a  tibia  4  months  after  the  inser- 
tion of  inlay  graft  AB.  C  is  piece 
of  broken  silver  wire  inserted  at  a 
previous    unsuccessful    operation. 


INLAY   BONE    GRAFT    IN    FRACTURES 


169 


and  perfectly  immobilized  by  external  splints  or  internal  metal 
devices  do  not  unite.  (See  Fig.  88.)  In  other  words,  it  is  clear 
that  the  surgical  problem  which  presents  itself  is  not  the  securing 
of  better  fixation  and  a  more  close  approximation  of  the  fragment 
ends  by  bone  removal  and  freshening,  but  the  furnishing  of  an 


'S^M.       '     ■      'A        •        It      ^  V 


W-y-J.  1;:"  i  .-^^ 


•;v 


■ .  J^f^~ 


HAf 


■J 


Fig.  110. — Microphotoyrapli  of  a  section  taken  from  the  end  of  a  fragment  of  an 
ununited  fracture.  To  demonstrate  the  microscopical  appearance  of  bone  which  has 
undergone  sclerotic  changes.  The  bone  is  partially  necrotic  as  manifested  by  the 
few  and  poorly  stained  nuclei.  The  attempt  at  regeneration  is  slight  and  abortive, 
there  being  few  active  osteoblasts. 


efficient  internal  splint  and  at  the  same  time  supplying  a  bone- 
growing  and  osteoconductive  element  which  spans  these  sclerosed 
areas  and  is  closely  and  favorably  contacted  with  the  healthy 
vascular  osteogenetic  bone  in  each  fragment  beyond  the  ebur- 
nated  area  and  distal  to  the  point  of  fracture.     The  inlay  bone 


170 


BONE-GRAFT   SUllGERY 


A 


Fig.   111.  Fig.   112. 

Figs.  Ill  and  112. — Ununited  fracture  of  the  radius  after  four  operations,  and  the 
last  Lane's  plate  in  position.  The  large  amount  of  bone  destruction  from  the  contact 
with  metal  is  shown  at  A.     B  is  a  fragment  of  silver  wire  put  in  at  a  former  operation. 


INLAY   BONE    GRAFT   IN    FRACTURES 


171 


graft  fulfils  all  these  requirements  and  even  more,  in  that  it  acts 
as  a  strong  stimulus  to  osteogenesis  on  the  part  of  the  host 
fragments  themselves. 

In  three  cases  where  there  had  been  non-union  and  even  loss 
of  bone,  following  severe  comminution  or  osteomyelitis  with 
death  of  the  complete  diameter  of  ends  of  the  fragments  after 
Lane  plating,  amputation  or  marked  shortening  was  avoided  by 
spanning  these  areas  with  long  inlays.  In  one  case,  where  2}yi 
in.  of  the  tibia  had  been  destroyed  by  osteomyelitis,  the  graft 
was  placed  so  as  to  span  the  infected  cavity,  and  although  it  was 
impossible  to  cover  the  graft  at  this  point  on  account  of  a  large 
sinus  in  the  skin,  nevertheless  granulations  slowly  covered  up 
the  graft,  none  of  which  sequestrated,  and  a  perfect  result  was 
obtained.     (See  Figs.  153,  154  and  155.) 


Fig.  113. — Drawing  illustrating  technique  employed  in  the  application  of  the  graft 
in  Figs.  Ill  and  112.  The  twin  saw  has  cut  from  A  to  5  and  is  in  process  of  cutting 
from  C  to  D.  The  graft  was  made  larger  from  B  to  C  so  as  to  fit  into  the  hiatus'and 
furnish  shoulders  to  prevent  muscle  pull  shortening  the  radius. 


FRESH  FRACTURES 

Time  for  Operation. — In  fresh  fractures,  the  most  desirable 
time  for  operation  is  from  the  fifth  to  the  fifteenth  day  after  the 
injury.  This  allows  time  for  the  absorption  of  the  exudates  in 
the  region  of  the  fracture,  and  for  improvement  in  the  drainage 


172 


BONE-GRAFT   SURGERY 


Figs. 


Fig.    114.  Fig.    115. 

11-1  AND   11.5. — Rontgenogram  of  same  case  as  Figs.  Ill  and  112  after  union 


had  been  obtained  bj'  a  tibial  inlay  graft.  The  fragment  ends  had  been  so  much 
disintegrated  by  contact  with  the  screws  and  plate  that  a  considerable  shortening 
had  occurred.  The  graft  was  inserted  so  as  to  span  a  hiatus  of  over  y>  in.,  and 
the  radius  was  restored  to  nearly  its  normal  length.  For  technique  see  diagram, 
Fig.  113.  A  is  rontgenogram  taken  6  weeks  after  insertion  of  graft.  5  is  6  months 
later  and  shows  progress  of  the  adaptation  of  the  graft  to  the  bones  into  which  it  is 
inserted. 


INLAY   BONE    GRAFT    IN    FRACTURES 


173 


of  the  lymphatic  system;  also  the  ends  of  the  bones  have  be- 
come covered  with  fibrin  and  have  gone  through  the  processes 
preparatory   to   repair.     All   the   conditions   are   favorable   for 


Fig.    116.  Fig.    117. 

Figs.  116  axd  117. — Rontgenogram  of  an  ununited  fracture  of  the  tibia  of  4 
months'  duration.  This  patient  sustained  two  fractures  of  the  fibula,  one  about  3 
in.  from  its  lower  end  and  the  other  about  3  in.  from  the  upper  end.  The  frac- 
ture of  the  tibia  was  a  three-fragment  oblique  fracture  and  was  immediatelj-  Lane 
plated;  A  indicates  the  third  fragment.  Both  of  the  two  fractures  of  the  fibula  united  and 
the  plated  tibia  fracture  did  not  unite.  This  rontgenogram  shows  considerable  bone 
destruction  both  from  the  plate  and  the  screws  which  have  loosened  and  come  out  of  the 
bone. 

operating,  and  by  this  time  the  usual  means  of  reducing  and 
fixing  the  fracture  have  been  tried  and  their  failure  to  accom- 


174 


BONE-GRAFT    SURGERY 


Fig.  118. — Rontgenogram  of  the  same  case  as  Figs.  110  and  117,  6  weeks  after  the 
removal  of  the  Lane's  plate  and  a  sliding  inlay  graft  had  been  brought  down  from  the 
upper  fragment  and  firm  union  had  resulted.  C,  C,  C  indicates  the  bone-graft  pegs 
which  were  used  to  fix  in  place  the  inlay  AB.  The  pegs  were  made  from  the  strip  of 
bone  removed  from  the  lower  fragment  for  the  purpose  of  forming  a  gutter  bed  for 
the  sliding  inlay. 


INLAY   BONE    GRAFT    IN    FRACTURES  175 

plish  the  desired  result  demonstrates  the  necessity  for  operation. 
A  longer  delay  is  not  desirable,  as  nature's  efforts  at  repair  and 
the  appearance  of  contractures  increase  the  difficulties  of  opera- 
tive reduction. 

Arbuthnot  Lane  favors  early  operation,  to  which  there  are 
several  disadvantages.  Much  tissue  is  so  injured  that  its  re- 
sisting power  is  lowered,  and  hence  there  is  increased  danger  of 


7t 


"W; 


Fig.  119. — H:i\vlcy  tnlilc  This  talile  is  six-cially  dc'si^nt'd  for  the  treatment  of 
fractures  by  the  closed  or  open  method.  It  provides  almost  perfect  control  of  the 
extremities,  and  makes  reduction  and  immobilization  more  accurate  and  certain.  The 
extremities  can  be  placed  in  various  positions,  so  that  flexion,  extension,  abduction  and 
rotation  can  be  regulated,  reliable  traction  obtained,  and  lateral  pressure  applied 
directly  to  the  fracture  ends.  After  reduction  the  limb  can  be  immobilized  without 
changing  its  position  or  releasing  the  traction. 

This  photograph  shows  the  table  in  position  for  the  treatment  of  fractures  of  the 
lower  extremity.  All  the  work  of  manipulation  or  operation  is  done  with  the  patient 
on  a  flat  surface  and  the  limbs  held,  not  by  assistants,  but  by  fixed  supports.  The  table 
top  is  made  with  a  section  which  can  be  lowered,  leaving  the  patient  suspended  for  the 
application  of  plaster,  and  then  raised  while  the  cast  is  hardening. 

This  table  is  well  adapted  to  rontgenographic  examination  of  fractures. 


accidental  infection.  The  patient  may  be- — and  is  likely  to 
be — in  a  state  of  shock.  There  is  an  increased  danger  of  opera- 
tive complications,  such  as  pneumonia,  delirium  tremens,  etc. 
The  skin  may  be  oedematous,  infiltrated,  and  excoriated,  and 
primary  union  of  the  tissues  difficult  to  obtain. 

The  following  lesser  advantages  of  early  operation  may  be 
enumerated:  The  tissues  are  freshly  lacerated,  there  is  no  effu- 


17(3 


IJONE-GRAFT    SURGERY 


Fig.  120. — Hawley  tabic.  Table  with  section  of  top  depicsscd,  leaving  post  with 
sacral  support  and  head  rest  projecting.  The  latter  is  mounted  on  runners,  so  that  its 
position  can  be  adjusted  to  different  subjects.  With  the  sliding  foot-pieces  it  becomes 
equally  suited  to  the  treatment  of  adults  and  children.  This  lowering  section  can  be 
raised  or  depressed  at  will  and  is  automatically  locked  when  raised. 


Fig.  121. — Hawley  table.  An  ordinary  3-in.  muslin  Ijandage,  in  the  centre  of 
which  has  been  sewn  a  piece  of  Mexican  felt  4  in.  wide  bj'  15  in.  long,  is  used  to  secure 
the  foot  to  the  traction  foot-piece.  This  acts  as  a  protective  ciaff  for  the  ankle.  To 
this  cuff  are  stitched  two  heavy  woven  straps,  so  placed  that  the  pull  will  be  in  a  line 
just  forward  of  the  heel.  After  this  bandage  is  snugly  applied,  the  foot  is  placed 
against  the  foot-plate  and  the  straps  fastened  to  the  buckles. 


INLAY   BONE    GRAFT    IN    FRACTURES 


177 


sion  into  the  periosseous   structures,  and   the   lymphatics  are 
freely  open. 

Preparation  of  Patient. — The  general  preparation  is  not  dif- 
ferent from  that  required  for  any  major  surgical  procedure. 
The  local  preparation  should  be  generous  in  its  extent  and  by  the 
iodine  method,  which  should  be  carried  out  both  on  the  night 


Fig.  122. — Hawley  table.  The  foot  is  held  in  firm  right-angled  flexion  and  the 
force  of  the  traction  applied  so  as  to  draw  the  heel  downward  and  maintain  this  position. 
A  plaster  cast  includes  the  foot  to  the  base  of  the  toes  and  encloses  the  foot  plate.  To 
release  the  foot  and  cast,  the  straps  are  cut  and  the  foot  plate  lifted  out.  When  power- 
ful traction  has  been  employed,  slits  in  the  plaster  at  the  back  and  front  of  the  ankle 
are  cut,  to  relieve  the  constriction  and  prevent  pressure  sores. 

before  and  on  the  day  of  the  operation  in  the  most  thorough 
manner. 

In  all  fractures  of  the  lower  extremities  an  efficient  traction 
apparatus  of  some  type  should  always  be  available  at  the  time  of 
operation.  In  the  author's  opinion,  the  Hawley  table  is  the  most 
ideal  traction  apparatus  for  handling  these  cases.  The  traction 
can  be  applied  with  a  limb  in  any  degree  of  abduction  or  flexion, 
which  is  frequently  a  great  advantage,    especially  in  fractures  of 

12 


178 


BONE-GRAFT    SURGERY 


Fig.  123. — Hawley  table.  Flexion  and  abduction  of  the  thigh  in  the  treatment 
of  subtrochanteric  fractures  of  the  femur  with  or  without  counter-pressure  on  the  upper 
fragment.  There  is  a  material  advantage  in  having  the  knee  flexed,  over  the  customary 
thigh  flexion  with  the  knee  extended,  in  that  the  relaxation  of  the  powerful  hamstrings 
greatly  aids  reduction,  the  quadriceps  also  being  relaxed  by  the  hip  flexion.  The 
traction  obtained  with  the  knee  flexed  is  quite  as  effective  as  with  the  knee  in  extension. 
It  is  often  advantageous  in  many  tibial  and  femoral  fractures  to  immobilize  with  some 
flexion  of  the  hip  and  knee,  because  flexion  naturally  aids  relaxation,  and  the  angles  in 
the  cast  make  the  immobilization  more  secure. 


Fig.  124.  Hawley  table.  Subject  with  the  legs  in  extreme  abduction,  the  Whit- 
man position  for  the  treatment  of  fracture  of  the  neck  of  the  femur.  The  rotation  of 
the  femur  is  controlled  by  the  foot-plate.  This  picture  shows  the  heavy  felt  pad  used 
to  protect  the  perineum,  and  the  U-shaped  perineal  post,  similar  to  the  double  posts, 
is  designed  to  avoid  pressure  on  the  urethra. 

Attachment  used  for  support  of  the  trunk  and  upper  extremities.  The  position  of 
the  patient  is  reversed  with  the  spine  and  head  resting  on  this  narrow  board.  Traction 
on  the  arms  is  applied  laterally.  The  patient  lies  on  the  table  with  the  top  raised, 
except  during  the  process  of  immobilization. 


INLAY   BONE    GRAFT    IN    FRACTURES 


179 


the  upper  third  of  the  femur  (see  ilhistration,  Fig.  123).  The 
neutral  position  should  be  made  the  most  of  in  any  fracture 
where  certain  muscles  are  exerting  a  strong  displacing  force. 
In  other  words,  the  reduction  should  be  accomplished  and  the 
plaster-of-Paris  fixation  dressing  should  be  applied  without  the 
position  of  the  limb  being  changed  or  the  traction  released  at  all. 
This  dictum  applies  in  any  case,  wiiether  operative  or  non- 
operative  methods  have  been  employed,  also  irrespective  of  the 


f        i 


Fig.  125. — Hawley  table.  Suppuit  mil  tiaction  of  the  left  arm  with  counter- 
traction  by  a  wide  sling  around  the  body.  This  position  is  used  for  operations  on  the 
humerus  and  for  reduction  of  fractures  of  both  bones  of  the  forearm  (also  for  the  re- 
duction of  shoulder  dislocation). 

type  of  the  internal-fixation  agent,  if  one  has  been  used.  No 
internal-fixation  appliance  will  for  any  length  of  time  withstand 
the  pull  of  strong  muscles  at  cross  angles  to  the  fractured  part, 
as  screws  will  pull  out  and  wire  will  cut  completely  through  the 
bone  if  union  has  not  taken  place. 


TECHNIQUE  OF  INLAY 

Armamentarium  Necessary  for  Inlay-graft  Operation. — (1) 
Hawley  fracture  table.     (2)  Two  Lambotte  clamps.     (3)  Low- 


180 


BONE-GRAFT    SURGERY 


Fig.  126. — A  case  of  ununited  fracture  of  the  tibia  after  the  application  of  Lane's 
plate.  The  fragment  ends  of  the  tibia  were  in  perfect  apposition  and  an  inlay  (AB) 
was  slid  down  from  C,  the  upper  fragment.  This  case  is  illustrative  of  how  simple  the 
inlay  operation  can  be  when  the  fragments  are  already  in  position.  This  case  was  done 
in  18  minutes,  including  the  closure  of  the  skin.  E  indicates  screw  hole  of  former 
Lane's  plate. 


INLAY   BONE    GRAFT    IN    FRACTURES  181 

man  or  Berg  clamp.  (4)  Albee  electric-operating  bone  set,  with 
twin  rotary  saws,  burrs,  drills,  dowelling  attachment,  etc.  (5) 
Periosteum  elevator.  (6)  Lane  bone  spatula.  (7)  Chisels, 
osteotomes,  and  mallets.     (8)  Lion  jaw  forceps. 

Author's  Technique  of  Inlay -graft  Operation  for  Fractures 
(Fresh  and  Ununited). — If  traction  is  required,  the  patient  is 
placed  on  a  traction  table,  preferably  the  Hawley  table.  The 
perineal  counter-traction  post  and  patient  are  properly  adjusted. 
The  foot  or  hand  is  bandaged  to  the  extremity  traction  plate. 
(See  Fig.  122.)  A  generous  skin  incision  is  made  overlying  the 
point  of  fracture,  and  when  possible  should  be  made  to  the  side 
of  the  intended  site  of  the  transplant.  The  fascia  and  muscles 
overlying  the  point  of  fracture  and  the  fragment  ends  are  opened 
by  scalpel  and  blunt  dissection,  and  the  region  of  the  fracture 
well  exposed. 

If  the  fracture  is  an  ununited  one  and  the  fragments  are  in 
good  apposition,  merely  a  part  of  the  fibrous  union  is  removed 
with  a  thin  sharp  osteotome.  In  executing  the  inlay  technique, 
the  periosseous  structures  are  disturbed  as  little  as  possible  and 
the  relationship  of  the  fragment  ends  left  undisturbed  if  possible. 
This  is  important  in  minimizing  the  amount  of  local  trauma.  In 
this  connection  it  is  desirable  to  emphasize  the  pronounced  in- 
hibitory influence  of  severe  trauma  to  cellular  proliferation, 
and  especially  to  osteogenesis.  In  no  line  of  work  is  there 
greater  danger  of  devitalizing  trauma  than  in  bone  work,  and 
this  applies  not  only  to  the  bone  itself  but  to  the  surrounding 
soft  tissues.  A  resulting  infection  of  any  of  the  involved  tissue 
may  interfere  with  a  successful  result. 

Traumata  may  arise  from  the  retraction  of  powerful  muscles 
and  their  soft  tissues — especially  where  too  short  an  incision 
has  been  employed  in  the  operative  treatment  of  a  fracture — • 
from  bone  elevators  or  levers,  bone  clamps,  the  macerating  and 
jarring  effects  of  dull  and  blunt  chisels,  etc.  Too  great  emphasis 
cannot  be  placed  upon  the  importance  of  making  the  skin  inci- 
sion of  sufficient  length  in  all  operative  fracture  work. 

The  periosteum  is  incised  longitudinally  and  peeled  back  to 


182 


BONE-GRAFT   SURGERY 


Fig.   127.  Fig.   128. 

Figs.  127  axd  128. — A  is  a  rontgenogram  taken  5  weeks  after  an  oblique  frac- 
ture of  the  lower  third  of  the  femur  with  a  considerable  shortening,  in  a  muscular 
individual.  Two  unsuccessful  attempts  had  been  made,  before  the  author  saw. this 
case,  to  hold  these  fragments  with  Lane's  plates.  /  is  a  long  fracture  in  the  lower  frag- 
ment, which  resulted  from  one  of  these  previous  operations;  cd,  in  B  is  graft  obtained 
from  the  well  tibia  on  account  of  the  rarefaction  of  the  bone  in  upper  fragment;  e,  e 
are  bone-graft  pegs  which  were  made  from  the  strip  of  bone  removed  to  produce  the 
gutter  in  the  upper  fragment  and  were  used  to  fix  the  inlay  in  its  gutter.  This  case 
illustrates  the  peculiar  efficacy  of  the  inlay  graft  in  holding  difficult  obliciue  fractures. 


INLAY    BONE    GRAFT    IN    FRACTURES 


183 


either  side  in  the  form  of  flaps,  exposing  the  bone  which  is  to  be 
removed  for  the  purpose  of  forming  a  gutter  in  the  fragment  or 


Fig.  129. — Anterior-posterior  and  lateral  view  of  a  fresh  fractiuf  of  the  femur  after 
fixation  of  the  fragments  by  a  sliding  inlay  graft  from  the  upper  fragment.  AB  is 
inlay  graft;  C,  C  are  the  pegs  holding  it  in  place.  This  case  had  been  treated  by  con- 
servative  means  for  Sji   weeks   before  operation   with   2  in.   of  over-riding. 

fragments,  as  the  case  may  be.  If  the  inlay  graft  is  to  be  ob- 
tained from  the  proximal  fragment,  the  periosteum  on  this  frag- 
ment is  not  disturbed,  because  it  is  always  desirable  that  the 


184  BONE-GRAFT    SURGERY 

graft  include  periosteum  us  well  as  eiulosteuni  and  marrow  sub- 
stance. In  fresh  fractures,  the  graft  material  can  practically 
always  he  taken  from  the  fragments  themselves,  as  the  osteo- 
genetic  function  of  this  bone  has  not  become  impaired.  In  most 
of  our  later  cases  of  non-union  the  graft  material  has  also  been 
taken  from  the  fragments,  with  uniform  success.  In  such  cases, 
however,  the  inlay  fragment  shoidd  always,  when  possible,  be 
obtained  from  the  upper  fragment  and  slid  downward  into  the 
distal  fragment.  This  is  important  on  account  of  the  large 
amount  of  rarefaction  which  always  appears  in  the  distal  frag- 
ment of  a  pseudo-arthrosis  of  long  standing,  and  the  relatively 
smaller  amount  of  osteoporosis  in  the  proximal  fragment. 

The  author's  inlay  technique  varies  somewhat  according  to 
individual  cases  and  requirements.  The  strength  of  the  graft 
can  be  made  to  vary  over  wide  limits.  Its  thickness  will  vary 
according  to  whether  it  is  obtained  from  the  upper  or  the  lower 
portion  of  the  antero-internal  aspect  of  the  tibia.  Unless  there 
is  some  reason  to  the  contrary,  it  is  better,  as  a  rule,  to  obtain 
the  graft  from  the  lower  part,  where  the  bone  cortex  is  thicker, 
stronger,  and  osteogenetically  more  active.  The  crest  of  the 
tibia  at  its  lower  third  furnishes  the  strongest  graft  on  account 
of  its  increased  thickness  of  cortex  and  the  fact  that  two  cortical 
tables  meet  here. 

In  small  bones,  such  as  those  of  the  forearm,  the  inlay  is  best 
held  in  place  by  kangaroo  tendon,  either  placed  in  drill  holes  to 
the  side  of  the  groove  or  wrapped  completely  about  the  bone  ends. 
In  fresh  fractures  of  large  bones,  such  as  the  femur,  w^here  the 
marrow  cavity  has  not  become  filled  w^ith  new-formed  bone  and 
there  is  nothing  to  prevent  the  inlay  from  slipping  into  the 
marrow  cavity,  the  graft  and  gutter  beds  are  made  wider  at 
their  periphery  than  at  the  marrow  side. 

The  fragment  ends  are  freed  and  strong  traction  applied  by 
means  of  the  traction  screw  on  Hawley  table.  Lambotte  clamps 
are  placed  on  each  fragment,  and  the  bone  is  manipulated  into 
apposition  and  adjusted  so  that  the  ends  fit  together  perfectly. 
Loose  fragments  are  replaced  in  their  proper  positions  or  are  re- 


INLAY   BONE    GRAFT    IN    FRACTURES  185 

moved  as  seems  wise.  When  the  ends  are  in  apposition  they  are 
held  so  either  by  strong  traction  or  by  the  use  of  a  Lowman  or 
Berg  clamp  placed  on  the  fragments.  If  the  fragment  ends 
cannot  be  brought  into  apposition,  it  is  not  of  serious  moment 
when  the  inlay  graft  is  used.  It  is  not  necessary  to  shorten  the 
limb  in  order  to  get  satisfactory^  apposition,  as  it  would  be  if  metal 
fixation  plates  were  being  used.  The  graft  can  safely  be  allowed 
to  span  a  hiatus  of  any  length. 

The  graft  to  be  employed  is  usuallj^  removed  from  the 
fractured  bone — generally  the  proximal  fragment — and  then  slid 
into  a  groove  one-half  its  length  which  has  been  prepared  for  it 
in  the  distal  fragment.  In  a  femur,  the  sliding  inlay  should  be 
about  5  to  6  in.  long. 

TECHNIQUE  FOR  INLAY  GRAFT  WITH  WEDGE  CROSS-SECTION 

The  removal  of  both  long  and  short  grafts  is  started  by 
making  parallel  cuts  I32  to  i{g  in.  deep,  with  the  twin  saws 
adjusted  at  a  suitable  distance  apart,  depending  upon  the  size 
of  graft  and  gutter  to  be  formed.  The  purpose  is  to  outline  a 
graft  of  uniform,  width  throughout  its  whole  extent.  These 
parallel  saw-cuts  are  then  continued  through  the  cortex  to  the 
medullary  cavity  with  the  single  motor  saw  held  at  such  an 
angle  as  to  cause  the  cuts  to  converge  in  approaching  the 
medullary  cavity,  in  order  to  prevent  the  graft  when  pressed 
tightly  into  position  from  slipping  into  the  medullary  cavity. 
The  ends  of  the  grafts  are  freed  with  transverse  cuts  made  with 
either  a  very  small  motor  saw  or  a  narrow  chisel.  The  thickness 
of  the  saw^  blade  makes  sufficient  difference  in  the  size  of  the 
graft  and  gutter  to  allow  the  inlay,  when  slid  into  position,  to 
sink  slightly  below  the  borders  of  the  gutter,  thus  furnishing  a 
margin  of  the  gutter  sides  above  the  graft  into  which  holes  are 
drilled  obliquely  to  receive  the  autogenous  dowel  pegs. 

The  inlay,  which  has  a  wedge-shaped  cross  section,  is  pressed 
tightly  into  position  and  held  there  firmly  by  either  a  Lowman 
or  a  Berg  clamp  while  the  holes  are  drilled  and  the  dowel  pegs 
inserted.     It  maj^  be  necessary  or  wise  to  allow  the  drill  to  sink 


186 


BONE-GKAFT   SURGERY 


Fig.  130. — Rontgenogram  of  an  ulii  ununited  fracture  at  the  lower  third  of  the 
femur  with  a  marked  over-lapping.  A  bone  graft  has  been  removed  from  the  crest  of 
the  tibia  and  inlaid  into  the  lower  end  of  the  upper  fragment  and  inserted  into  the 
lower  fragment  by  tunnelling  this  fragment.  A  proper  reduction  was  impossible  on 
account  of  adherent  popliteal  vessels  to  the  lower  fragment.]  ^ 


INLAY   BONE    GEAFT   IN    FRACTUEES 


187 


a  fraction  of  or  its  whole  diameter  into  the  edge  of  the  graft. 
The  pegs  are  obtained  by  spHtting  the  short  segment  (removed 
from  the  distal  fragment  for  the  purpose  of  making  the  groove 


DRILL  HOLES 


Fig.   131.  Fig.   132. 

Fig.  131. — Diagram  showing  the  method  of  preparing  the  ununited  fragments  of 
the  lower  end  of  the  femur,  which  cannot  be  got  into  alignment  or  apposition  (see  X-ray, 
Fig.  130),  for  the  reception  of  the  autogenous  bone  graft  procured  from  the  tibia.  The 
drill  holes  are  made  in  the  four  corners  of  the  square  tunnel  as  a  guide  in  cutting  out 
the  bone  with  the  narrow  chisel.  The  graft  is  forced  into  this  tunnel  at  this  end  and 
the  other  end  is  then  placed  in  the  gutter  of  the  upper  fragment  and  secured. 

Fig.  132. — Diagram  showing  the  gutter  in  the  lower  end  of  the  upper  fragment 
completed,  also  the  square  tunnel  prepared  in  the  lower  fragment  of  tliis  ununited 
fracture  of  the  femur;  also  the  drawing  to  the  left  shows  the  outline  of  the  graft  to  be 
removed  from  the  crest  of  the  tibia.  Note  that  it  includes  two  surfaces  and  the  crest 
and  is  cut  to  the  marrow  cavity. 


for  the  inlay)  into  two  or  three  fragments,  and  pushing  them 
through  the  author's  motor  lathe  or  dowelling  instrument.     Each 


188 


BONE-GRAFT    SURGERY 


A 


.SMALL  GRAFTS 


of  these  dowels,  which  is  loiip;  enough  to  make  two  or  three 
fixation  pegs,  is  driven  Hghtly  into  the  lioles  over  th(>  inkiy, 

and  while  an  assistant  holds  its  distal 
end  with  a  forceps  the  surgeon  cuts 
the  peg  off  with  the  small  motor  saw 
at  the  desired  place.  The  remaining 
portion  of  the  dowel  is  then  used  in  like 
manner  for  additional  pegs. 

In  ununited  fractures  of  large  bones, 
where  the  marrow  cavity  is  filled  with 
a  bone  plug  which  prevents  the  inlay 
from  slipping  into  the  medullary  canal, 
and  in  all  the  smaller  bones  and  in  all 
individual  cases  where  the  mechanics 
are  favorable,  the  twin  motor  saw  alone 
is  used  in  removing  the  inlay  graft  and 
preparing  its  gutter  bed.  In  fractures 
of  long  bones  where  the  difficulty  of 
fixation  is  great,  the  inlay  is  held  in 
place  by  the  bone-graft  pegs  or  heavy 
kangaroo  tendon,  or  both,  as  seems 
best.  The  fragments  are  motor  drilled 
on  each  side  of  the  gutter,  and  the 
tendon  is  placed  as  indicated  by  the 
diagram.  When  the  graft  and  its 
gutter  bed  are  formed  wholly  by  the 
twin  saws,  the  graft  is  just  twice  the 
thickness  of  a  saw-cut  narrower  than 
its  bed,  which  allows  space  for  heavy 
,  ,,    ,  ,, ,     • .  •   ..      kangaroo  tendon  to  be  placed  between 

01   the  long  graft  to  aid  in  the  °  ^ 

rapid  production  of  new  bone,    the  graft  and  gutter  Wall  ou  each  side. 

This   is    illustrative    of   a   case 

where  the  fragments  cannot  be  In   the   Case    of   Small  boUCS,   SUCh  aS 

brought  into  alignment.  ,1  t  i  ±^  •      i-  r 

the  radms  or  ulna,  the  encirclmg  oi 
the  fragments  with  the  tendon  is  very  efficacious  in  holding 
the  insert  firmly  in  its  place.  In  severe  comminuted  fractures 
from  gunshots  or  other  causes,  where  there  is  a  space  to  be 


Fig.  133. — Diagram  is  a 
lateral  view  of  an  ununited 
fracture  of  the  lower  end  of  the 
femur  with  the  autogenous 
bone  graft  in  position  uniting 
the  fragments;  also  note  that 
the  space  at  A  has  .small  grafts 
placed  about   this  free  portion 


INLAY   BONE    GRAFT    IN    FRACTURES 


189 


spanned  and  the  length  of  the  limb  is  to  be  maintained  by  the 
inlay,  it  is  best  to  tongue  and  groove  the  ends  of  the  graft  and 
bone  cortex  of  gutter  ends.  The  groove  should  be  in  the  end 
of  the  graft,  and  the  tongue  in  the  gutter  ends.  Any  tendency 
to  shortening  of  the  limb  by  muscular  pull,  etc.,  causes  the  tongue 
and  groove  joints  to  become  all  the  more  firmly  locked  and  is 
thus   a   sure  preventive   of   shortening.     The    graft,    however 


Fig.  134. — Demonstrates  author's  technique  of  obtaining  the  sliding  or  tibial  graft 
with  sawcuts  converging  to  the  marrow  cavity.  This  technique  is  used  in  fresh  frac- 
tures of  large  bones.      (See  Fig.  135.) 

sinall,  will  in  time  hypertrophy,  under  the  action  of  Wolff's  law, 
and  will  become  the  size  and  strength  of  the  bone  whose  sub- 
stance it  is  supplying.  The  value  of  the  graft  in  this  type  of 
cases  cannot  be  over-estimated. 

An  important  point  in  the  technique  of  bone  grafting  in  its 
application  to  all  types  of  fractures  is  that  the  transplant  should 
be  of  sufficient  length.  In  the  case  of  the  intramedullary  graft 
this  might  afford  a  great  deal  of  difficulty,  but  with  the  inlay 
graft  it  is  accomplished  with  ease.  A  graft  6  in.  long  can  be 
inlaid  as  easily  as  one  2  in.  in  length.     Several  unsuccessful 


190 


BONE-GRAFT   SURGERY 


-^ 


Fig.  135. — Illustrates  the  author's  method  of  making  use  of  the  bone  graft  with 
wedge  cross-section  removed  from  the  fractured  fragments  or  from  some  other  bone, 
as  the  tibia,  in  the  treatment  of  fresh  as  well  as  ununited  fractures  of  long  bones.  The 
smaller  drawing  3,  top  of  page,  illustrates  the  graft  dowel  pegs  in  position  holding  the 
graft  in  place,  and  also  shows  the  shape  of  the  graft  and  gutter  bed  on  cross-section. 
c.  Dowel  grafts  in  place. 


Fig.  136.— Diagram  of  the  cross-section  of  a  graft  inlaid  in  a  long  bone,  illustrating 
the  manner  of  its  fixation  by  kangaroo- tendon  sutures  passed  through  drill  holes  at 
either  side  of  the  gutter.  Note  that  one  suture  passes  through  the  drill  holes  and  loops 
up  over  the  graft  and  is  tied;  also  note  that  a  second  suture  passes  under  the  graft  and 
through  the  same  drill  holes,  thus  preventing  the  graft  from  falling  into  the  medullary- 
cavity.     The  gutter  and  graft  in  this  instance  are  formed  entirely  by  the  twin  saws. 


INLAY   BONE    GRAFT    IN    FRACTURES 


191 


results  have  come  to  the  author  in  which  he  is  sure  the  con- 
tributing causes  of  failure  were  the  shortness  of  the  graft,  the 
intramedullary  method,  and  the  fact  that  the  graft  did  not 
extend  sufficiently  beyond  the  sclerosed  fragment  ends  to  offer 
adequate  and  exact  contact  with  vascular  osteogenetic  bone. 
In  one  of  these  cases  the  inlay  graft  had  been  used,  but  the 


Fig.  137. — Is  a  drawing  of  author's  modification  of  his  inlay  graft  adapted  to  ex- 
tremely atrophied  fragments  with  marked  conical  ends  (see  Fig.  138)  and  bones  of 
forearm,  clavicle,  etc.,  which  are  small.  The  ends  are  split  with  motor  saw  and  the 
resulting  halves  are  wedged  apart  with  the  wedge  ends  of  the  grafts  which  are  moulded 
into  this  form  during  their  removal  from  the  well  tibia,  aa  Indicates  the  fixing  kan- 
garoo tendon  which  can  be  wrapped  completely  about  the  fragment  end,  or  it  may  be 
placed  in  drill  holes  through  both  graft  and  fragment  ends;  h,  h  are  bone-graft  pegs, 
which  may  or  may  not  be  used  in  large  bones  to  supplement  the  tendon  in  fixing  the 
graft  in  place.     This  drawing   is  from  the  skiagram  of  an  actual  case. 


technique  had  been  most  defective  and  the  unsuccessful  result 
was  not  surprising.  The  case  was  a  long-standing  ununited 
fracture,  with  marked  sclerosis  of  bone  extending  into  each  frag- 
ment for  about  lH  in.,  as  was  shown  by  the  X-ray.  The  graft 
insert  was  only  about  2  in.  long  and  did  not  even  extend  through 
the  eburnated  bone.     The  graft  should  have  been  not  less  than 


192 


BONE-GRAFT   SURGERY 


5  ill.  long,  thus  extending  well  into  the  vascular  osteogenetic 
bone  of  both  fragments,  beyond  the  sclerosed  area.  This  is 
an  important  technical  point  and  cannot  be  too  strongly 
emphasized. 


^ 


^ 


Fig.  138. — Ununited  fracture  of  both  tibia  and  fibula  after  the  insertion  of  silver 
wire,  which  has  broken.  B  indicates  bone  destruction  from  contact  with  the  metal. 
The  fragments  were  soft  and  had  spindle-shaped  ends,  especially  at  A.  The  preferable 
technique  in  this  type  of  pseudarthrosis  is  to  split  the  fragment  ends  and  insert  wedge- 
end  grafts. 

In  pseudarthrosis  the  inlay  graft  may  vary  from  4  to  6  in. 
in  length— never  less  than  4 — according  to  the  size  of  the  bone 
fractured,  the  extent  of  osteogenetic  impairment,  or  the  amount 
of  comminution.  If  the  comminution  is  extensive,  or  if  the 
fracture  is  of  long  standing,  resulting  in  an  unusual  amount  of 


INLAY   BONE    GRAFT    IN    FRACTURES 


193 


osteoporosis  in  the  fragment  ends,  it  is  preferable  to  obtain  a 
transplant  from  the  sound  tibia,  in  which  case  the  graft  bed 
should  be  prepared  first  and  packed  with  a  saline  compress  in 
order  to  secure  a  sufficient  hsemostasis.     Two  parallel  saw-cuts 


\ 


Fig.  139. — Ununited  fracture  of  the  lower  end  of  the  humerus.  cc  indicates 
screw  holes  of  former  Lane's  plate,  AB  is  an  inlaj'  graft  inserted  by  faulty  technique, 
in  that  the  upper  end  of  the  graft  was  not  placed  completely  into  the  cortex  of  the 
proximal  fragment. 

are  made  lengthwise  in  the  fragment  ends,  extending  through 
the  complete  thickness  of  the  cortex  and  into  the  marrow  cavity. 
The  distance  between  the  motor  twin  saws  is  readily  adjusted, 
according  to  the  diameter  of  the  bone  and  the  point  of  fracture. 

13 


194 


BONE-GRAFT   SURGERY 


The  graft  is  then  removed  from  the  tibia,  either  from  the  crest 
or  from  the  aiitero-internal  surface,  according  to  the  strength 
required,  with  the  twin  saws  adjusted  as  they  were  in  making 
the  gutter.     In  this  way  an  accurate  fit  is  assured. 


Fig.  140. — Ununited  fracture  following  the  application  of  the  Lane  plate.  The 
screws  have  loosened  and  fallen  out.  Much  bone  destruction  from  contact  with  the 
metal  is  shown.  The  Lane  plate  was  removed  and  an  inlay  graft  from  the  tibia  in- 
serted with  excellent  result.      (See  Figs.  141,  142.) 


The  cuts  should  extend  2  or  3  in.  into  the  end  of  each  frag- 
ment, if  the  transplant  is  to  be  obtained  elsewhere,  as  for  instance 
from  the  tibia,  and  they  should  always  extend  far  enough  to 


INLAY   BONE    GRAFT    IN    FRACTURES 


195 


reach   well   into   active   osteogenetic   bone   of   each   fragment. 
While  the  saws  are  cutting,  they  are  constantly  sprayed  with 


j^Btay^^ 


Fig.   141.  Fig.   142. 

Figs.  141  and  142. — Same  case  as  Fig.  140,  after  removal  of  Lane's  plates.  The 
rontgenogram  shows  the  bone  inlay  in  place  with  small  grafts  placed  about  fragment 
ends.     Firm  union  had  occurred  in  4  weeks. 

saline  solution,  supplied  either  by  squeezing  a  saline  compress 
held  over  the  saw  or  by  an  automatic  spray  attachment  furnished 
by  a  sterile  tube  from  a  douche  bag  suspended  over  the  table. 


196 


BONE-GRAFT    SURGERY 


This  prevents  excessive  heating  of  the  bone  from  the  friction 
of  the  revolving  saws. 


Fig.  143. — A  severely  conimiiuitetl  fracture  of  the  femur  which  had  not  united  or 
showed  any  callus  formation  after  10  weeks  of  Buck's  extension  and  coaptation  splints. 
A  strong  graft,  AB,  obtained  from  tibia  inserted  in  fragments  C  drawn  to  it  with 
kangaroo  tendon.  The  union  was  immediate  and  has  remained  firm  over  2  years. 
This  case  was  referred  by  the  kindness  of  Dr.  J.  B.  Bissell. 

The  ends  of  the  graft,  as  well  as  the  strips  of  bone  which, 
when  removed,  produce  the  gutter  graft  beds,  are  cut  for  pur- 


INLAY   BONE    GRAFT    IN    FRACTURES 


197 


pose  of  removal  with  a  circular  saw  so  small  that  it  does  not  en- 
croach into  the  walls  of  the  gutter  at  the  sides. 

If  the  graft  is  to  be  obtained  from  one  of  the  fragments,  the 
twin-saw  cuts  are  made  twice  the  distance  into  that  fragment. 
The  strip  of  bone  thus  obtained  is  slid  endwise  into  the  gutter 


Fig.  144. 


-By  the  kindness  of  Dr.   Emil  Geist.     Fractured  dislocation  of  the  femur. 
Author's  inlay  graft  was  used  for  fixation.     (See  Fig.  145.) 


in  the  other  fragment.  The  fragments  are  fixed  by  holding  the 
inlay  firmly  in  place  by  heavy  kangaroo  tendon  or  by  bone-graft 
pegs,  as  the  case  indicates.  The  kangaroo  tendon  is  passed 
through  holes  drilled  b}^  the  motor  in  the  cortex  on  either  side 


198 


BONE-GRAFT    SURGERY 


of  the  giittcj-.  The  leiulon — two  strands  in  each  fragment — 
is  threaded  tlirough  from  one  side  of  the  gutter  to  the  other  and 
is  then  pulled  uj)  from  the  gutter  in  the  form  of  loops,  under 
which  the  inlay  graft  is  forced  into  place,  and  then  the  kangaroo 


Fig.  145. — Rontgenogram  of  a  transverse  fracture  of  the  femur  showing  perfect 
alignment.  The  inlay  bone  graft  fixing  these  fragments  can  be  faintly  demonstrated 
near  the  centre  in  the  long  axis  of  the  bone.     A  perfect  result  was  produced. 

tendon  is  tied  over  it.  The  bone  removed  in  the  form  of  saw- 
dust by  the  twin  saws  causes  the  graft  to  be  just  enough  smaller 
than  the  gutter  to  allow  room  for  the  kangaroo  tendon. 

If  the  bone  is  large  and  the  problem  of  mechanical  fixation 
is  more  difficult,  bone-graft  pegs  may  be  used   exclusively  or 


INLAY   BONE    GRAFT    IN    FRACTURES  199 

may  be  supplemented  b}^  kangaroo  tendon.  The  bone-graft 
pegs  are  made  by  sawing  longitudinally  the  piece  of  bone  re- 
moved for  the  purpose  of  producing  the  gutter  into  two  or  three 
strips,  which  are  turned  into  dowel  pegs  by  pushing  them  through 
the  motor  lathe.  The  inlay  graft  is  held  in  place  by  clamps  while, 
with  the  electric  drill,  holes  are  drilled  into  the  cortical  bone  of 
the  sides  of  the  gutter  bed.  The  pegs,  which  always  fit  accu- 
rately, on  account  of  the  drill  being  of  the  same  diameter  as 
the  aperture  of  the  dowel  cutter,  are  forced  into  place  by  a 
few  gentle  blows  with  a  mallet,  and  are  cut  off  with  a  motor 
saw  close  down  so  that  just  enough  projects  to  hold  the  inlay 
securely  in  place.  The  original  dowel  pegs  are  from  2  to  3  in. 
long,  and  will  make  from  two  to  four  fixation  pegs.  Numerous 
small  fragments  of  bone  are  placed  in  between  the  ends  of  the 
fragments  and  about  the  graft  at  that  point,  just  before  closing  the 
wound.  These  fragments  should  be  of  active  osteogenetic  bone, 
and  are  best  made  by  a  Rongeur  forceps.  Macewen  was  the 
first  to  point  out  that  the  smaller  the  bone  graft,  the  greater  its 
relative  osteogenesis.  This  has  been  repeatedly  confirmed  by 
the  author  from  both  surgical  and  experimental  experience. 

By  this  technique  foreign  bodies  are  entirely  avoided.  The 
material  used  is  either  autogenous  bone  or  absorbable  material. 
The  fit  of  the  inlay  and  the  pegs  must  be  accurate  by  virtue  of 
the  motor-cutting  tools  employed. 

This  technique  also  allows  the  most  ideal  coaptation  of  the 
graft  to  its  bed;  that  is,  every  graft  should  comprise  four  differ- 
ent tissues — namely,  periosteum,  compact  bone,  endosteum,  and 
marrow  substance;  and  this  is  the  only  technique  which  per- 
mits of  the  coaptation  of  each  of  these  individual  elements  to 
those  of  the  recipient  bone.  In  three  cases  where  there  had  been 
non-union  and  loss  of  bone  following  severe  comminution,  or 
osteomyelitis  with  death  of  the  complete  diameter  of  the  ends  of 
the  fragments  after  Lane  plating,  amputation  or  marked  short- 
ening was  avoided  by  spanning  the  areas  with  long  inlays.  In 
one  case,  where  2}4  in.  of  the  tibia  had  been  destroyed  by  osteo- 
myelitis, the  graft  was  placed  so  as   to  span  the  granulating 


200 


BONE-GRAFT   SURGERY 


cavity,  and  although  it  was  impossible  to  cover  the  graft  at  the 
affected  ])()nit  on  account  of  a  large  sinus  in  the  skin,  neverthe- 


FiG.  140. — Before  and  after  insertion  of  bone  graft,  bb,  for  ununited  fracture  of 
the  tibia  of  10  years'  duration  in  a  child  of  11  years.  Several  unsuccessful  operations  to 
secure  union,  including  an  intermedullary  graft,  had  been  done.  The  graft  was  inlaid 
into  the  lower  fragment  by  the  author's  usual  technique.  There  had  been  so  much 
atrophy  in  the  upper  fragment,  and  its  lower  end  had  become  so  conical  shaped,  that  it 
was  split  upward  for  about  II2  in.  and  the  upper  wedge  end  of  the  graft  was  inserted 
into  the  saw-cut  cleft.  The  resulting  tongue  and  groove  joint  was  held  by  two  strands 
of  kangaroo  tendon  wrapped  about  it.  (See  Fig.  137.)  Firm  union  between  the  graft 
and  the  fragments  occurred  immediately. 

less  granulations  slowly  covered  up  the  graft — none  of  which 
sequestrated — and   a  perfect   result   was  obtained    (see    Figs. 


INLAY   BONE    GRAFT    IN    FRACTURES  201 

153,  154  and  155).     One   could  not  wish  better  proof  of  the 
germ  resisting  property  of  the  bone  graft. 

Another  instance  which  ilhistrates  the  marked  efficacy  of 
the  inlay  graft  is  that  of  a  case  referred  to  the  author  by  Dr. 
W.  W.  Plummer  at  a  clinic  held  at  Buffalo  in  March,  1914. 
The  patient  was  a  boy,  11  years  of  age.  In  1904,  when  he  was 
a  year  old,  both  bones  of  the  right  leg  were  fractured,  followed 
by  complete  non-union  due  to  neglect.  In  1906  an  operation 
was  done  for  non-union.  An  intramedullary  graft  obtained 
from  the  well  leg  was  used.  On  account  of  bone  atrophy,  the 
cortex  of  the  tibial  fragments  had  to  be  split  longitudinally  with 
a  chisel.  In  9  weeks  there  was  a  very  fair  degree  of  rigidity. 
A  few  weeks  later  the  boy  fell  and  refractured  the  tibia,  and  this 
fracture  failed  to  unite.  In  1909  another  operation  for  non- 
union was  performed.  This  time,  on  account  of  bone  atrophy, 
the  region  of  the  bone  ends  was  opened  and  several  small  pieces 
of  bone,  taken  from  the  well  tibia  and  including  periosteum  and 
medulla,  were  introduced.  This  operation  also  failed.  In 
March,  1914,  the  author  operated,  using  the  motor  bone  outfit, 
and  an  inlay  graft  taken  from  the  w^ell  tibia  was  inserted.  The 
graft  was  fixed  into  the  lower  fragment  by  the  usual  inlay  tech- 
nique, but  the  lower  end  of  the  upper  fragment  proved  to  be  so 
atrophied  and  conical  in  shape  (see  Fig.  146A)  that  it  was  decided 
to  split  it  upward  with  the  motor  saw"  for  about  2  in.  The 
upper  end  of  the  graft  was  shaped  into  a  wedge  at  the  time  it 
was  removed.  This  wedge  end  was  forced  into  the  saw-cut  in 
the  lower  end  of  the  upper  fragment  (see  Fig.  137,  diagram  of 
author's  technique),  and  the  lower  end  of  the  graft  was  fixed 
into  the  low^er  fragment  by  the  usual  inlay  technique.  Aplaster- 
of-Paris  splint  was  applied,  which  was  removed  early  in  June, 
1914.  Union  was  certain.  At  present  the  patient  is  walking 
on  the  leg,  w^hich  is  short  from  the  old  deformity.  The  union 
of  the  tibia  is  secure,  and  the  blood  supply  of  the  extremity  is 
much  improved.  This  case  of  relief  after  10  years  of  non-union 
is  a  striking  illustration  of  the  efficacy  of  the  inlay  autogenous 
graft. 


202  BONE-GRAFT   SURGERY 

Four  of  the  author's  series  of  ununited  fractures  had  previ- 
ously been  unsuccessfully  operated  upon  1)}'  the  intramedullary 
technique.  These  failures  are  largely  explained  by  the  fact 
that  this  technique  affords  a  faulty  histological  contact  of  graft 
to  host  fragments,  even  when  well  executed. 

Two  important  advantages  of  the  inlay  technique  as  applied 
to  ununited  fractures  are:  first,  the  ease  with  which  sufficient 
contact  with  osteogenetic  bone  beyond  the  sclerosed  area  can 
be  secured;  and  second,  the  readiness  with  which  this  contact 
can  be  varied  in  accordance  wdth  the  difficulties  encountered. 
The  more  desperate  the  case  and  the  more  frequently  it  has  been 
unsuccessfully  operated  upon,  the  longer  must  be  the  inlay  trans- 
plant. One  of  the  author's  series,  an  ununited  fracture  of  the 
radius  and  ulna,  had  been  operated  upon  unsuccessfully  seven 
times — including  the  use  of  Lane's  plates,  silver  wire,  nails,  and 
intramedullary  grafts — and  it  was  then  pronounced  impossible 
to  secure  union.  (Fig.  147.)  The  inlay  grafts  employed  were 
very  long,  extending  to  the  tips  of  the  styloid  processes  and  well 
beyond  the  eburnated  area  in  the  upper  fragments.  In  5  weeks 
there  was  firm  union.  The  X-ray  showed  that  all  through  there 
was  firm  union  of  graft  to  that  portion  of  the  distal  fragment 
beyond  the  eburnated  area.  There  was,  however,  no  union  be- 
tween the  fragments  themselves  or  between  the  eburnated  area 
in  the  ends  of  the  fragments  and  the  graft.  The  result  would 
undoubtedly  have  been  a  failure  had  the  graft  inlays  been  short 
and  had  not  extended  well  beyond  the  areas  of  the  fragment 
ends.  Again,  it  would  have  been  most  difficult  to  have  inserted 
medullary  grafts  without  breaking  the  ulna  graft  while  inserting 
the  radial  transplant,  or  vice  versa.  To  the  author's  knowledge, 
a  united  fibula  has  been  broken  in  attempting  to  insert  the  intra- 
medullary graft  into  the  tibia.  It  w^ould  have  been  most  diffi- 
cult to  have  reached  and  secured  satisfactory  contact  with 
osteogenetic  bone  beyond  the  eburnated  zone.  This  difficulty, 
however,  is  inherent  in  the  intramedullary  technique,  and  no 
doubt  was  largely  responsible  for  the  previous  failure  from 
this  operation  in  this  particular  case. 


INLAY   BONE    GRAFT    IN    FRACTURES 


203 


Fig.  147. — Rontgenograms  of  ununited  fractures  of  the  radius  and  ulna  of  4  years' 
duration,  after  seven  unsuccessful  open  operations  to  secure  union,  including  Lane's 
plating,  wiring  and  intramedullary  bone  grafting.  The  rontgenograms  show  the  large 
holes  and  bone  destruction  in  both  radius  and  ulna,  which  originated  from  the  screws 
of  the  former  Lane's  plates  and  the  metal  contact  of  the  plate  itself. 


204 


BONE-GRAFT   SURGERY 


A  strong  iirguiiiuiit  for  the  inlay  tochniciuo,  as  compared  with 
the  intramedullary,  is  its  universal  applicability  to  all  types  of 
fractures  of  the  long  bones,  however  near  the  joints  they  may 


A  B 

Fig.  148. — A  is  a  roritgenogriini  taken  5  weeks  after  the  successful  implantation  of 
tibial  inlay  grafts;  B  was  taken  6  months  after  the  operation  and  shows  that  the  grafts 
have  lost  their  sharpness  of  outline  and  are  taking  on  the  density  and  characteristics  of 
the  bone  in  which  they  are  inserted.  On  account  of  the  desperate  nature  of  the  case, 
very  long  implants  were  used  and  the  wisdom  of  this  is  shown  at  C,  where  there  is  no 
union  between  the  fragn^ents  or  between  the  proximal  fragment  and  the  graft  for  a 
space  of  two-thirds  of  an  inch  from  the  end  of  the  fragment,  although  there  has  been 
firm  union  for  5  months,  because  of  the  long  graft  coming  in  contact  with  the  vascular- 
osteogenetic  bone  back  of  the  sclerosed  bone  at  the  ends  of  the  fragments. 


be.     A  good  illustration  is  an  ununited  fracture  of  the  tibia  in 
good  apposition  near  the  ankle-joint,   where  the  fibula  has  be- 


INLAY   BONE    GRAFT    IN    FRACTURES 


205 


come  united.  The  accessible  portion  of  the  fibrous  union  is 
removed.  There  is  no  occasion  to  disturb  the  relationship  of 
the  fragments.  The  thickened  periosteum  is  split  and  peeled 
sidewise  on  the  lower  fragment  onlj^,  and  with  the  motor  twin 
saws  and  a  narrow  chisel  a  groove  is  made  in  the  lower  fragment 


A  B 

Fig.  149. — Drawings  illustrating  the  technique  carried  out  in  the  case  of  which 
Figs,  147  and  148  are  rontgenograms.  A  indicates  grooves  and  grafts  before  insertion 
and  B,  after  the  insertion  of  graft  and  kangaroo-tendon  fixation  sutures.  The  grafts 
were  long  and  were  placed  into  the  radial  side  of  the  radius  and  the  ulnar  side  of  the 
ulnar.  The  radial  and  ulnar  fragments  were  very  satisfactorily  separated  by  drawing 
them  to  the  grafts  with  kangaroo  sutures  as  indicated  in  B.  This  is  a  special  important 
feature  of  the  inlay  graft  as  compared  with  that  of  the  intramedullary  type  in  its 
application  to  fractures  of  both  bones  of  the  leg  or  forearm.      (See  also  Fig.  137.) 

completely  to  the  tip  of  the  malleolus,  if  the  fragment  is  very 
short.  Then,  by  means  of  the  same  twin  saw,  a  cortical  graft 
4  or  5  in.  long  is  removed  from  the  upper  fragment  and  slid 
down  into  the  groove  in  the  lower  fragment. 

When  the  fracture  is  very  near  a  joint,  as  the  ankle,  and  the 
lower  fragment  affords  a  very  short  contact,  the  graft  can  be 


206 


BONE-GRAFT    SURGERY 


extended  to  the  tip  of  the  malleohis  so  that  joint  support  will  be 
largely  supplied  by  the  end  of  the  graft  which  is  in  the  malleolus 
as  in  a  shell,  even  if  by  chance  bony  union  should  not  occur 
between  the  graft  and  lower  fragment,  provided,  of  course,  that 
union  has  taken  place  between  the  upper  fragment  and  the  graft, 


Fig.  150. — Rontgenogram  of  a  comminuted  fracture  at  the  lower  end  of  the  tibia 
with  displacement  of  the  fragments.  This  is  the  same  case  as  Fig.  151,  2  months 
after  the  fracture. 


which  should  be  made  certain  by  a  long  inlay  and  consequent 
extensive  contact.      (Fig.  151.) 

In  exceptional  instances,  there  is  no  necessity  for  using  any 
means  to  hold  the  graft  in  place. 

To  fix  the  inlay  in  place,  the  question  arises  of  the  choice  for 
the  purpose  between  bone  pegs  and  heavy  kangaroo  tendon 


INLAY   BONE    GRAFT    IN    FRACTURES 


207 


placed  in  drill  holes  or  wrapped  entirely  around  the  bone  when 
it  is  small,  as  the  bones  of  the  forearm. 

An  important  mechanical 
feature  of  the  inlay,  which 
should  not  be  overlooked,  is  that 
if  it  is  inserted  in  proper  relation- 
ship to  the  forces  which  are 
causing  displacement  it  becomes 
by  its  ow^n  inherent  mechanics 
a  most  effective  fixation  agent, 
irrespective  of  the  means  used 
to  keep  it  in  place.  An  illustra- 
tive case  is  that  of  a  very  stout 
woman  with  a  1-year  ununited 
fracture  of  the  tibia  (about  1  in. 
from  the  ankle-joint).  (Fig.  151.) 
There  was  a  marked  displacement 
of  the  lower  fragment  and  foot 
posteriorly.  The  bone  ends  were 
freshened  and  the  lower  fragment 
was  forced  forward  into  place. 
Although  there  was  a  strong 
tendency  for  this  fragment  to 
spring  back  into  its  old  position, 
a  long  inlay  placed  into  the  inner 
side  of  the  fragments  held  them 
securely  by  virtue  of  the  me- 
chanics of  the  inlay,  without  de- 
pending upon  the  kangaroo  ten- 
don and  the  graft  pegs  which  held 
it  in  place.  On  the  other  hand, 
if  this  inlay  had  been  placed  into 
the  anterior  or  posterior  surface 
of  the  tibial  fragments,  its  fixa- 
tion force  would  have  been  wholly  dependent  upon  the  pegs  or 
tendon  which  held  it  in  place.     (See  also  Fig.  107.) 


Fig.  151. — Ununited  fracture  of 
lower  end  of  tibia  of  1  year's  duration 
in  a  woman  of  250  lb.  The  lower 
fragment  was  markedly  displaced  pos- 
teriorly. AB  indicates  graft  in  which 
was  inserted  into  the  malleolus  com- 
pletely to  its  tip  on  account  of  the 
shortness  of  the  lower  fragment.  The 
inherent  mechanics  of  this  inlay  into 
the  inner  surface  of  the  tibia  prevented 
the  relapse  of  the  position  of  the  lower 
fragment.      (See  Fig.  152.) 


208 


BONE-GKAFT    8UH(iEUY 


The  author  has  repeatedly  and  successfully  used  the  bone 
graft  for  spanning  through  tuberculous  foci  in  Pott's  disease  of 
the  spine  and  tuberculosis  of  the  ankle-  and  knee-joints.  The 
cortical  bone  graft  has  always  withstood  pui-c  tuberculous  infec- 
tion, provided  it  had  satisfactory  contact  with  healthy  bone  on 
each  side  of  the  infected  focus.  It  will  also  resist  attenuated 
pyogenic  infection  under  similar  conditions,  as  has  been  proven 


.4  B 

Fig.  152. — Bone-graft  inlay  for  fracture  of  the  internal  malleolus.  A  shows  inlay 
graft  removed  from  its  bed  by  the  twin  motor  saw,  dotted  lines  in  shaft  and  fractured 
malleolus  indicating  the  gutter.  B  shows  the  external  malleolus  restored  to  its 
position  and  the  inlay  fixed  by  kangaroo-tendon  suture.  The  kangaroo  tendon  in  the 
malleolus  is  placed  through  drill  hole  in  lower  end  of  graft. 

by  experiments  conducted  by  Phemister  and  the  author  in  both 
surgical  (Fig.  154)  and  laboratory  work.  (See  Albee:  ''Experi- 
mental Study  of  Bone  Growth  and  the  Spinal  Bone  Transplant," 
Jour.  A.  M.  A.,  April  5,  1913,  Ix,  pp.  1044-49,  also  Chapter  III.) 
The  importance  of  this  inherent  germ-resisting  property  of  the 
bone  graft  is  readily  apparent,  in  that  it  doubly  assures  its  trust- 
worthiness as  a  general  surgical   agent    (when   compared   with 


INLAY   BONE    GRAFT    IN    FRACTURES 


209 


metal).  Especially  is  this  true  in  its  application  to  compound 
fractures  in  which  infection  is  feared  or  where  a  mild  infection 
has  already  occurred.     The  following  is  an  illustrative  case: 


Fig.  153.  Fig.   154. 

Figs.  15.3  and  154. — A  is  a  lontgenograin  of  an  infected,  ununited  fracture  6 
months  after  the  insertion  of  two  Lane's  plates.  The  plates  were  removed  a  few 
weeks  after  their  insertion,  cc  Indicates  a  sequestrum  of  the  complete  diameter  of 
the  tibia  from  the  upper  screw  holes  of  the  Lane  plate  to  lower  end  of  upper  fragment 
of  which  F  is  the  photograph,  and  g  and  h  are  the  screw  holes.  B  is  rontgenogram  4 
months  after  the  insertion  of  the  graft.  Bone  union  between  fragments  and  graft  was 
immediate,  although  there  was  a  discharging  sinus  and  a  hiatus  of  2  in.  at  the  time  of 
operation.      (See  text.) 

A  man,  45  years  of  age,  came  to  the  author  with  an  infected 
ununited  fracture  of  the  tibia  of  6  months'  duration,  and  gave  the 

14 


210  BONE-GRAFT    SURGERY 

following  history:  Six  iiioiiths  previously  he  hud  sustained  a 
fracture  of  the  lower  third  of  the  tibia  and  fibula.  The  tibia 
was  immediately  plated  with  two  lonj;-  J.ane's  plates.  Infection 
occurred,  and  the  plates  were  removetl  in  3  weeks'  time.  The 
wound  continued  to  discharp;e  profusely,  and  an  X-ray  examina- 
tion revealed  a  sequestration  of  the  complete  diameter  of  the 
upper  fragment  of  the  tibia,  from  the  upper  screw  holes  of  the 
Lane  plates  down  to  the  end  of  the  fragment.  The  discharging 
sinus  was  increased  in  size  and  the  sequestrum,  about  2i^^  in. 
long,  comprising  the  entire  diameter  of  the  tibia,  was  removed. 
The  cavity  thus  produced  was  packed  and  the  leg  was  put  up 
in  a  plaster  case,  making  use  of  the  united  fibula  to  prevent 
approximation  of  the  remaining  tibial  fragments  and  conse- 
quent shortening  of  the  leg.  At  the  end  of  8  weeks  the  sinus 
was  still  discharging  a  considerable  amount  of  sero-purulent 
material  and,  on  account  of  the  large  cavity  between  the  frag- 
ment ends,  the  prognosis  as  to  when  the  sinus  would  heal  was 
most   uncertain. 

As  the  patient  was  very  anxious  to  have  something  done 
immediately  to  get  a  union  of  his  tibia,  it  was  decided  to  make 
the  attempt,  and  with  the  use  of  the  motor  twdn  saw  a  strong 
cortical  graft  was  dragged  down  from  the  upper  fragment  into  a 
groove  made  with  the  same  instrument  in  the  lower  fragment. 
(The  cavity  w^as  first  curetted  out  carefully  and  filled  with  tinc- 
ture of  iodine — 3.5  per  cent. — and  the  whole  operating  outfit 
was  then  changed.)  The  inlay  was  slid  into  place  from  the 
upper  fragment,  spanning  an  hiatus  of  23^^  in.,  and  held  with  peg 
grafts  which  were  made  on  the  operating  table  by  splitting  into 
three  portions  with  the  motor  saw  the  fragment  of  bone  removed 
from  the  lower  fragment  in  making  the  groove  for  the  inlay,  and 
then  shaping  these  portions  into  three  long  pegs  by  means  of  the 
motor  lathe.  On  account  of  the  large  size  of  the  sinus,  it  was 
impossible  to  cover  about  an  inch  of  the  centre  of  the  graft, 
where  it  spanned  across  the  sinus  opening.  However,  much  to 
our  gratification,  the  convalescence  was  most  satisfactory; 
granulations  covered  the  exposed  portion  of  the  graft  very  rap- 


INLAY   BONE    GRAFT    IN    FRACTURES  211 

idly,  and  there  was  firm  union  between  transplant  and  fragments 
in  6  weeks'  time.  In  4  months'  time,  Wolff's  law  had  caused 
the  graft  to  hypertrophy,  and  the  hiatus  between  the  tibial 
fragments  had  completely  filled  in  and  the  long  bone  had  appar- 
ently become  as  strong  as  it  had  ever  been.     (Fig.  155.) 

This  case  has  a  very  important  bearing  in  demonstrating 
the  striking  superiority  of  the  bone  graft  as  compared  with 
internally  inserted  metal.     The  graft  was  inserted  into  a  wound 


Fig.  155. — Photograph  of  same  case  as  Figs.  153  and  154.  A  indicates  large 
sinus  at  the  bottom  of  which  is  the  uncovered  graft,  which  it  was  impossible  to  entirely 
cover  at  the  operation.  This  sinus  was  discharging  sero-purulent  material  at  the  time 
the  graft  was  inserted.  Nevertheless,  the  graft  healed  in  immediately  and  covered  over 
with  granulations. 

which  even  showed  macroscopic  evidence  of  infection;  never- 
theless it  healed  in  rapidly  and  has  given  no  trouble  since, 
although  it  is  over  a  year  since  the  operation.  The  surgical 
technique  of  inserting  a  metal  plate  must  be  of  the  most  rigid 
and  special  type  in  order  to  avoid  infection  in  clean  cases,  as 
pointed  out  by  Lane;  and  if  the  slightest  infection  occurs,  it  is 
very  likely  to  extend  the  whole  length  of  the  plate  and  to  its 
screws,  and  the  plate  must  come  out.     In  this  case,  as  well  as  in 


212  BONE-GRAFT   SURGERY 

several  others,  the  inhiy  graft  was  successful  and  resisted  infec- 
tion that  was  already  present. 

In  view  of  these  experiences,  the  value  of  this  method  in 
compound  eomniinuted  fracture  from  gunshot  or  other  causes, 
mildly  infected  or  not,  is  apparent. 

Experimental  graft  work  on  the  dog  demonstrated  still  more 
conclusively  the  bacteria-resisting  properties  of  the  bone-graft. 
Wounds  have  become  virulently  septic  on  the  second  and  third 
days  after  operation,  laying  bare  the  graft  which  was  bathed  in 
pus  at  the  bottom  of  the  wound.  Nevertheless,  either  a  portion 
or  the  whole  of  the  grafts  took  and  lived. 

Whatever  be  the  modes  of  internal  fixation — whether  the 
Lane  plate  or  the  inlay  graft — the  liml)  should  be  firmly  immo- 
bilized in  a  plaster-of-Paris  splint  in  as  nearly  a  neutral  position 
as  possible,  ^.e.,  a  posture  of  the  limb  which  causes  the  relaxation 
of  those  muscles  which  have  a  displacing  influence  in  that  par- 
ticular fracture.  If  this  be  done,  inlay  or  peg  grafts.  Lane  plates 
or  neck  of  femur  spikes  will  not  bend  nor  break  during  the  period 
of  the  post-operative  fixation.  Weight-bearing  function,  in  the 
presence  of  non-union  or  soft  callus,  and  bone  absorption  are 
the  causes  for  the  yielding  of  internal  metal-fixation  splints. 

In  all  cases  of  persistent  non-union  where  syphilis  and  other 
systemic  conditions  are  contributing  causes  of  meagre  callus 
formation,  these  conditions  should  be  treated  before  operation 
is  undertaken. 

FIXATION  BY  BONE-GRAFT  DOWEL  PEGS 

Epiphyses,  condyles,  tubercles,  trochanters,  tuberosities,  bone 
fragments,  etc.,  may  be  very  satisfactorily  secured  to  the  bone 
from  which  they  have  been  fractured  by  the  employment  of 
bone-graft  dowel  pegs,  which  are  aseptically  and  speedily  made 
by  the  author's  dowel  instrument  (see  chapter  on  motor  outfit). 
Their  accurate  fit  is  secured  by  employing  the  proper  drill  to 
make  the  hole  into  which  they  are  driven. 

The  material  from  which  thej^  are  made  can  always  be  ob- 


INLAY   BONE    GRAFT    IN    FRACTURES  213 

tained  from  the  crest  of  the  tibia  if  it  cannot  be  more  readily 
obtained  in  the  original  field.  Enough  has  already  been  said  to 
emphasize  the  superiority  of  the  bone-graft  pegs  over  metal  nails 
or  screws.  Screws  of  dead  bone  or  ivory  have  a  certain  theoret- 
ical value  in  that  they  become  absorbed,  as  a  rule,  after  a  very 
long  time.  From  a  practical  standpoint,  however,  they  act 
precisely'  as  foreign  bodies  in  the  bone  and  soft  tissues,  and  may 
at  any  time  have  to  be  removed. 

OTHER  METHODS  OF  FIXATION 

The  Parkhill  clamp  has  most  of  the  disadvantages  of  the 
Lane  plate,  and  in  addition  leaves  an  open  wound  down  to  the 
region  of  fracture.  Either  this  type  of  clamp  or  that  of  Lam- 
botte  has  an  argument  for  its  employment  in  the  treatment  of 
compound  fractures  in  that  no  foreign  material  is  placed 
in  the  wound  across  the  line  of  fracture.  Since  the  advent  of 
the  inlay  graft,  however,  even  this  narrow  field  of  usefulness  for 
these  clamps  has  still  further  been  circumscribed. 

FIXATION   BY   ABSORBABLE   OR   NON-ABSORBABLE   LIGATURE 

MATERIAL 

It  is  only  on  the  rarest  occasions  that  a  wiring  operation 
should  be  done.  In  the  practice  of  the  author,  no  metal  appli- 
ances of  any  kind  are  ever  employed  for  the  internal  fixation  of 
broken  bones.  Metal  wire  is  not  only  a  foreign  body  with  all  its 
disadvantages,  but  it  (silver  wire  especially)  is  a  most  untrust- 
worthy fixation  agent,  as  it  so  frequently  breaks.  Many  ront- 
genograms,  both  those  observed  in  X-ray  laboratories  and  those 
in  the  author's  own  practice,  have  been  studied  by  him  and  show 
that  the  wire  has  either  broken  or  become  so  loose  as  to  be  of  no 
service,  with  the  fragments  nevertheless  in  good  position,  which 
means  that  the  fragments  would  have  remained  in  position  any- 
way, whether  the  wire  had  been  used  or  not. 

If  wire  is  to  be  used  at  all,  it  is  certainly  to  be  desired  that 
stronger  material  than  silver  wire  be  used.     The  varieties  most 


214  BONE-GRAFT    SURGERY 

commonly  employed  are  copper,  phosphor  bronze,  p;alvanized 
iron  wire,  and  twisted  steel  wire.  Personally,  the  author  is  in 
thorough  agreement  with  Hitzrot,  who  states  that  he  ''can  see 
no  use  for  any  of  these  types  of  non-absorbable  material,"  both 
because  of  their  non-disap})earance  in  the  tissues  by  absorption 
and  because  they  afford  so  little  real  fixation — certainly  no  more 
than  is  furnished  by  an  absorbable  ligature,  such  as  kangaroo 
tendon,  in  the  cases  in  which  this  type  of  fixation  is  suitable. 

Kangaroo  tendon  of  large  size  (especially  prepared  for  the 
author  by  Van  Horn  and  Sawtelle)  is  preferable  in  every  particu- 
lar to  silver  wire.  It  is  stronger;  it  does  not  cause  bone  absorp- 
tion; it  becomes  adherent  to  the  tissues  and  does  not  lie  in  a 
cavity  filled  with  a  serous  exudate,  as  wire  is  sure  to  do.  It  is  a 
much  more  trustworthy  fixation  agent,  as  wire  is  liable  to  crack 
in  the  process  of  insertion  and  then  give  way  from  muscle  pull  as 
the  patient  comes  out  of  his  ansesthesia,  or  at  some  later  time. 
Kangaroo  tendon  remains  for  not  less  than  40  days,  and  then 
becomes  absorbed.  Infection  may  start  about  wire  years  after 
its  insertion.     (Fig.  94.) 

CONTRA-INDICATIONS  TO  OPERATION 

These  do  not  differ  from  those  applying  to  operations  in 
general.  Infected  abrasion  of  the  skin  or  ulcers  near  the  field  of 
operation  are  to  be  carefully  avoided;  also  patients  with  actively 
suppurating  wounds  or  abscesses  in  any  part  of  the  body  should 
not  be  operated  upon  because  of  thd  danger  of  metastatic  infec- 
tion at  the  field  of  operation,  predisposed  by  the  lowering  of  local 
resistance  from  trauma  and  the  general  depression  arising  from 
the  operation. 

The  most  scrupulous  aseptic  technique  should  always  be 
observed. 

FIXATION  DRESSING 

The  plaster-of-Paris  splint  applied  over  a  thin  padding  of 
Shaker  flannel  or  cotton  wadding  to  protect  the  bony  promi- 
nences has,  in  the  handsof  the  author,  proved  to  be  by  all  means 


INLAY   BONE    GRAFT    IN    FRACTURES  215 

the  most  satisfactory.  It  can  be  readily  split  into  a  bivalvular 
splint  by  means  of  the  author's  motor  saw  (a  special  saw  being 
used  for  the  purpose)  or  by  the  Stille  cutter.  The  splint  can 
then  be  easily  removed  for  necessary  treatment,  etc. 

Other  satisfactory  splints  are  Stimson's  moulded  plaster-of- 
Paris  splints.  Splints  of  tin  or  wood-plastic  splints  of  felt, 
papier  mache,  celluloid,  etc.,  have  been  used,  but  aie  greatly  ex- 
celled by  plaster-of-Paris  ones  for  the  usual  fixation  dressing. 

As  stated  elsewhere,  the  limb  should  always  be  placed  in  such 
a  position  that  displacing  muscles  are  relaxed  by  approximating 
their  insertion  to  as  near  their  origin  as  is  practicable.  An  illus- 
tration would  be  the  flexion-abduction  posture  used  in  frac- 
tures at  the  lesser  trochanter,  for  the  purpose  of  relaxing  the 
psoas  magnus  and  short  trochanter  muscles  which  pull  the  upper 
fragment  into  that  position. 

AFTER-TREATMENT  OF  FRESH  FRACTURES 

After  the  insertion  of  the  inlay,  union  is  so  rapid  in  fresh 
fractures  that  massage  and  passive  motion  can  be  instituted 
somewhat  earlier  than  after  any  other  treatment.  This  should 
be  apparent  because  of  the  extensive  and  accurate  approximation 
of  the  bone  elements  involved  in  the  union  (namely,  the  graft 
and  the  fragments)  and  the  small  amount  of  callus  formation 
required  to  produce  bony  union.  Massage  and  passive  motion 
should  be  instituted  as  soon  as  the  w^ound  of  entrance  has  healed, 
or  at  about  the  end  of  the  second  week  after  the  operation,  and 
should  be  performed  by  a  trained  masseur,  the  splint  being 
replaced  after  each  treatment  until  bony  union  is  complete. 

Baking. — Baking  by  hot  air  is  especially  efficacious  in  frac- 
tures about  joints,  and  should  be  begun  at  the  same  time  with 
the  massage  and  passive  motion  and  should  immediately  pre- 
cede those  exercises. 

Hot  compresses,  consisting  of  towels  or  pads  of  cotton 
covered  with  gauze  wrung  out  of  very  hot  water  may,  in  certain 
cases,  be  of  service. 


211)  BONE-GRAFT    SXHIGEKY 

Jjinitnenis. — Liuiinoiits  have  no  special  therapeutic  effect 
except  that  they  encourage  massage  or  ru})bing.  Strong  lotions 
which  ixvc  \u\])\v  to  ])list(M'  \\w  skin  should  not  be  employed. 

AFTER-TREATMENT  OF  UNUNITED   FRACTURES   OR 
PSEUDARTHROSIS 

On  account  of  the  sluggish  osteogenesis  of  the  bony  elements 
making  up  a  pseudarthrosis,  a  support  should  be  continued 
much  longer  than  in  case  of  fresh  fractures.  In  the  more 
desperate  cases  some  support  should  be  continued  for  3  to  4 
months,  because  the  callus  formation  from  the  bone  ends  is  slow 
at  best  and  all  the  stress  may  be  borne  by  the  graft,  which  will 
hypertrophy  sufficiently  if  in  the  meantime  it  is  protected  from 
breaking. 

FRACTURE  OF  THE  CLAVICLE 

Recent  simple  fracture  of  the  clavicle  can,  as  a  rule,  be  satis- 
factorily reduced  and  maintained  in  position  by  the  usual  exter- 
nal methods.  In  rare  instances,  either  on  account  of  the 
obliquity  of  the  fracture  or  for  some  other  cause,  the  displace- 
ment cannot  be  controlled.  An  open  reduction  is  then  justi- 
fiable. The  open  reduction  of  the  fragments  may  be  all  that  is 
necessary,  without  resort  to  internal-fixation  appliances.  Is 
this  instance  local  infiltration  anaesthesia  may  be  adec^uate.  If 
bone  work  is  to  be  done,  general  anaesthesia  is  desirable.  It  is 
the  conviction  of  the  author  that  metal  plates  (Lane)  should 
never  be  employed  in  fracture  of  this  bone,  and  that  the  choice 
should  lie  between  kangaroo  tendon  and  the  inlay  bone  graft 
for  fresh  fractures.  The  inlay  graft  for  ununited  fractures  is 
the  operation  of  choice.  The  so-called  intramedullary  graft  is 
impossible  of  application. 

In  Aiinals  of  Surgery  for  September,  1914,  Dr.  H.  H.  M. 
Lyle  reports  a  case  of  ununited  fracture  of  the  clavicle  in  which 
he  implanted  a  bone  graft,  6  by  11.5  cm.,  from  the  tibia. 
The  graft  was  fastened  as  a  splint  on  the  outside  of  the  bone, 
spanning  the  point  of  non-union,  by  means  of  kangaroo  tendon 


INLAY   BONE    GRAFT    IN    FRACTURES 


217 


passed  through  the  graft  and  clavicle.  Twenty-seven  days  after 
the  operation  the  graft,  having  become  displaced  upward  and 
producing  a  pressure  necrosis  on  the  skin,  was  removed. 
''The  graft  was  smooth  and  clean  and  apparently  viable,  indi- 
cating that  bone  regeneration  had  already  begun."  The  wound 
healed  in  a  few  days,  and  a  week  later  blood  injections,  accord- 
ing to  the  Bier  method,  w^ere  begun.  Bony  union  and  a  satis- 
factory result  was  obtained.  Dr.  Lyle  remarks  that  in  this 
situation,  when  the  soft  parts  are  thin  and  it  is  difficult  to  secure 
immobilization,  a  bone  graft  should  not  be  used  as  a  splint  but 


Fig.   156. — Drawing  of  inlay  graft  inserted  for  an  ununited  fracture  of  the  clavicle. 
(For  techniciue,  see  also  Fig.  137.) 

rather  as  a  means  of  stimulating  bone  growth,  and  that  this  is 
the  chief  therapeutic  value  of  the  graft;  and  that  he  obtained 
better  results  from  the  use  of  this  bone  graft  than  from  thick 
ones.  This  case  is  a  strong  argument  in  favor  of  the  inlay  tech- 
nique, which  would  have  brought  the  surface  of  the  graft  level 
or  flush  with  that  of  the  clavicle  itself,  and  there  would  have 
been  no  danger  whatever  of  pressure  necrosis  of  the  overlying 
skin.  The  graft  should  consist  of  the  full  thickness  of  the  tibial 
cortex  with  periosteum,  endosteum,  and  some  marrow  substance, 
and  should  be  obtained  from  the  upper  portion  of  the  tibia 
where  the  cortex  is  not  so  thick.  Such  a  graft,  held  in  place  by 
kangaroo  tendon,  furnishes  perfect  fixation. 


218  BONE-GRAFT   SURGERY 

FRACTURE  OF  THE   OLECRANON 

In  fresh  fracture  of  the  olecranon  process,  opening,  drilHng, 
and  the  insertion  of  kangaroo  tendon  is  beUeved  to  be  the  best 
treatment.  In  ununited  fractures  of  this  process,  the  inlay 
graft  held  in  place  by  kangaroo  tendon  is  very  easy  of  applica- 
tion and  promises  better  results  than  any  other  treatment. 
The  graft  is  inlaid  completely  to  the  tip  of  the  olecranon  and  as 
far  into  the  shaft  as  the  amount  of  bone  sclerosis  indicates.  A 
sliding  graft  or  a  tibial  one  may  be  used,  as  conditions  indicate. 

FRACTURE  OF  BOTH  BONES  OF  THE  FOREARM 

Fracture  of  both  bones  of  the  forearm  requires  operative 
treatment  when  there  is  soft  tissue  between  the  fragments, 
when  it  is  compound,  or  when  proper  alignment  cannot  be  ob- 
tained by  the  usual  traction  methods,  wdth  the  patient  under  an 
anaesthetic.  Many  factors  unite  in  the  indications  for  and 
against  open  treatment  in  these  fractures. 

The  function  of  the  forearm  is  so  apt  to  be  interfered  with 
by  faulty  alignment  that  individuals  whose  livelihood  depends 
upon  a  strong  and  useful  arm  will  get  a  far  better  and  more 
rapid  result  from  an  open  operation  than  from  any  other  treat- 
ment. The  inlay  graft  affords  an  ideal  fixation  for  either  the 
fresh  or  the  ununited  fracture  of  the  bones. 

The  grafts  should  always  be  inserted  into  the  radial  side  of 
the  radius  and  into  the  ulnar  side  of  the  ulna,  unless  otherwise 
indicated.  Any  tendency  of  the  ulnar  and  radial  fragments  to 
approximate  each  other  is  mechanically  prevented  by  long 
inlays  thus  placed. 

The  grafts  are  best  taken  with  twin  saws  from  the  central 
portion  of  the  antero-internal  surface  of  the  tibia  and  are  fixed 
in  place  with  kangaroo  tendon  (or  technique.  Fig.  137). 

The  arm  should  be  put  up  in  a  position  midway  between 
pronation  and  supination,  in  a  plaster-of-Paris  splint  extending 
from  the  base  of  the  fingers  over  the  elbow,  thus  leaving  the  fin- 
gers free. 


INLAY   BONE    GRAFT    IN    FRACTURES 


219 


In  the  after-treatment,  active  motion  of  the  fingers  should 
be  encouraged  from  the  beginning.  In  fresh  fracture  cases, 
massage  and  passive  motion  of  the  wrist  and  elbows  should  be 
begun  in  the  third  week.  The  bone  healing  should  be  studied 
by  the  X-ray,  and  the  time  for  removing  the  sphnts  determined 
by  the  amount  of  callus  formation. 

When  Lane  plates  or  other  metal  fixation  appliances  are 
used  it  is,  as  a  rule,  necessary  to  leave  the  external  fixation  splints 
on  for  8  to  14  weeks,  and  "complete  use  of  the  arm  for  strenuous 


Fig.  157. — Technique  of  sliding  inlay 
graft  for  fracture  of  the  olecranon  proc- 
ess.    Arrows  indicate  drill  hole  in  graft. 


Fig.  158.— The  inlay 
graft  is  held  firmly  in  place 
with  kangaroo  tendon. 


labor  should  not  be  allowed  for  four  months"  (Hitzrot).  These 
periods  are  distinctly  shortened  by  the  employment  of  the  inlay 
graft,  because  of  its  own  osteogenesis  and  the  stimulus  it  affords 
to  the  fragments  themselves.  This  shortening  of  the  convales- 
cence should  be  expected  when  it  is  realized  that  the  influence 
of  the  metal  fixation  appliances  is  quite  the  opposite,  in  that  its 
contact  destroys  bone  and  inhibits  callus  formation. 

In  cases  of  pseudarthrosis,  supporting  splints  should  be  con- 
tinued for  a  much  longer  period,  according  to  the  nature  of  the 
case   and  the  amount  of  callus  formation. 


220  BONE-GRAFT    SURGERY 

FRACTURE  OF  THE  NECK  OF  THE  FEMUR 

Fracture  of  the  neck  of  the  femur  is  })y  all  means  the  most 
disabling  of  all  types  of  fractures.  These  fractures  were  for- 
merly regarded  as  occurring  mainly  in  old  age.  Recent  personal 
statistics,  as  well  as  those  of  other  surgeons  who  have  large 
fracture  clinics,  show  a  large  number  of  fractures  of  the  femoral 
neck  occuri'ing  in  individuals  below  the  age  of  45  or  50.  Senile 
osteoporosis,  associated  with  thinning  of  the  cortex  and  absorp- 
tion of  many  of  the  lamellae  of  the  spongiosa  of  the  neck,  is  the 
chief  cause  of  the  increased  frequency  of  this  fracture  in  the  aged ; 
and,  as  would  be  expected,  traumata  need  be  much  less  severe  to 
cause  fracture  in  the  aged  than  in  younger  individuals.  There 
seems  to  be  no  object,  as  far  as  treatment  or  prognosis  is  con- 
cerned, in  classifying  these  fractures  further  than  the  single 
term  ''fracture  of  the  neck."  The  terms  intracapsular  and 
extracapsular  are  inaccurate  and  misleading.  The  capsular 
insertion  to  the  neck  of  the  femur  is  oblique,  thus  causing  the 
joint  to  include  more  of  the  neck  on  its  anterior  and  inferior 
surfaces  than  on  the  posterior  and  superior. 

Then,  again,  most  fractures  are  oblique  and  diagonal,  and 
are  only  infrequently  strictly  transverse.  If  any  classification 
is  used,  that  of  Stimson  is  by  all  means  the  preferable  one,  i.e., 
subcapital,  or  fracture  through  the  neck,  and  fracture  at  the 
base  of  the  neck.  A  fracture  is  apt  to  occur  in  one  of  these  two 
places,  either  at  the  junction  of  neck  with  head  or  with  the  tro- 
chanter. The  associated  outward  rotation  in  epiphyseal  sepa- 
ration or  fracture  occurs  as  frequently  and  is  often  more 
pronounced  than  in  fractures  of  the  neck,  which  fact  cannot  be 
explained  by  a  more  fragile  posterior  portion  of  the  neck.  The 
predominance  of  the  external  rotators,  especially  the  short 
trochanteric  muscles,  is  believed  to  be  the  more  tenable  ex- 
planation. 

Shortening  depends  upon  the  lessening  of  the  angle  be- 
tween the  femoral  neck  and  the  shaft  or  a  sliding  by  of  the 
fragments. 


INLAY   BONE    GRAFT    IN    FRACTURES  221 

TREATMENT    OF   FRACTURE    OF   THE   NECK    OF   THE   FEMUR 

In  speaking  of  the  poor  results  obtained  in  treatment  of 
fractures  of  the  femoral  neck  by  the  conventional  methods,  an 
authority  states:  ''At  first  one  can  hardly  appreciate  how  start- 
ling these  results  are  unless  he  has  carefully  studied  various  series 
of  statistics,  and  wherever  the  usually  accepted  principles  of 
practice  are  employed — the  long  side  splints  with  Buck's  exten- 
sion— there  the  average  results  are  uniformly  unsatisfactory." 

Of  value  in  this  connection  are  the  conditions  existing  in  16 
cases  of  fracture  of  the  limb  observed  by  Scudder  many 
years  after  the  accidents.  "In  only  two  cases,  or  12  per  cent., 
could  it  be  said  that  the  leg  was  functionally  useful." 

Walker  studied  the  records  of  112  cases  of  fracture  of  the  neck 
of  the  femur  treated  in  Bellevue  Hospital  between  1906  and  1907. 
Only  15  cases,  or  13  per  cent.,  recovered  good  function. 

The  British  fracture  committee  tabulated  91  cases,  in  which 
87  of  the  patients  were  over  15  years  of  age.  Only  20  of  the 
adults,  or  23  per  cent.,  recovered  good  function. 

Unquestionably  Whitman's  abduction  method  offers  better 
results  than  the  foregoing.  Certain  men,  however,  have  not 
obtained  the  favorable  results  secured  by  Whitman. 

Cotton  offers  the  following  objections  to  this  treatment: 
"First,  many  men  are  inclined  to  doubt  the  locking  of  the  upper 
fragment  at  the  limit  of  abduction,  believing  rather  that  tension 
on  the  abductor  muscles  gives  the  limit  of  abduction;  second, 
there  is  real  danger  that  in  less  expert  hands  the  fragments  may 
be  forced  by  one  another — not  jammed  together;  third,  plaster 
spicas  in  stout  patients  do  not  hold  abduction  firmly." 

At  best,  fracture  of  the  neck  of  the  femur  is  one  of  the  most 
difficult  problems  in  all  surgery.  The  anatomico-mechanical 
conditions,  the  poor  blood  supply,  the  sluggish  osteogenesis,  and 
the  difficulty  of  fixation  are  all  potent  adverse  influences  to  se- 
curing satisfactory  union  and  good  functional  results,  and  it  is  be- 
lieved that  if  ever  radical  measures  are  justifiable  they  are  indi- 
cated in  the  treatment  of  this  desperate  condition.     Realizing 


222  BONE-GRAFT    SURGERY 

this,  certain  surgeons  have  employed  the  metal  spikes  to  assure 
better  approximation  and  fixation  than  could  be  obtained  by 
noii-oi)erative  measures.  This  method  has  not  given  uniformly 
good  results  because  of  the  failure  of  sufficient  callus  formation. 

An  illustrative  personal  case  was  that  of  a  woman  30  years 
of  age  suffering  from  a  fracture  of  the  neck  of  the  femur  un- 
united after  8  weeks.  There  was  no  destruction  of  the  fragments 
from  friction,  nor  was  there  any  systemic  disease  to  inhibit 
callus  formation.  It  was  a  favorable  case,  and  a  tin-plated 
square  steel  spike,  3}  2  in.  long,  was  driven  into  good  position 
longitudinally  through  the  centre  of  both  fragments  of  the  neck, 
which  were  in  excellent  apposition.  The  convalescence  was 
uneventful.  The  wound  healed  by  primary  union,  and  at  no 
time  was  there  a  temperature  above  half  a  degree  after  the  day 
following  the  operation.  The  operation,  however,  resulted  in 
failure,  and  non-union  occurred.  Fig.  159  is  a  skiagram  taken 
4  months  after  the  operation,  showing  that  the  spike,  owing  to 
its  own  weight  and  bone-destroying  influence,  had  dropped 
through  the  lower  portion  of  the  capital  fragment  and  no  longer 
engaged  it.  The  metal  spike  had  not  only  destroyed  bone,  but 
it  had  inhibited  callus  formation,  in  a  region  where  osteogenesis  is 
at  a  low  grade,  to  such  a  degree  that  it  prevented  union  or,  at  any 
rate,  was  a  contributing  cause  to  non-union. 

To  avoid  the  disadvantages  of  metal  the  author  began,  in 
1912,  to  use  a  bone-graft  peg  as  a  substitute  for  the  metal  spike 
(for report, see  author'sreportinMurphy's "Clinics, "June,  1913). 
If  this  bone  peg  is  placed  in  the  cervical  fragments  by  the  tech- 
nique described  elsewhere,  an  equally  satisfactory  amount  of 
internal  fixation  is  furnished  at  the  same  time  that  the  dis- 
advantages of  a  metallic  foreign  body  are  avoided,  and  the  ad- 
vantages of  a  living  bone  graft  gained. 

A  strong  autogenous  bone  peg,  accurately  fitted  into  a  hole 
drilled  longitudinally  through  the  neck  of  the  femur,  with  the 
fragments  in  good  position,  offers  unquestionably  the  most  ideal 
condition  for  the  rapid  and  satisfactory  union,  in  good  position, 
of  this  difficult  fracture.     In  other  words,  the  influences  adverse 


INLAY   BONE    GRAFT    IN    FRACTURES  223 

to  union,  enumerated  elsewhere,  are  better  overcome  by  this 
procedure  than  by  any  other  treatment;  also  every  argument  for 
the  autogenous  inlay  graft  in  ununited  and  selected  fresh  frac- 
tures of  shafts  of  long  bones  holds  equally  in  fractures  of  the 
neck   of   the  femur. 


Fig.  159. — This  spike  was  placed  in  the  centre  of  head  at  operation.  It  has  de- 
stroyed bone  and  dropped  out  of  the  capital  fragment  entirely,  non-union  resulting. 
(See  text.) 

Soft  tissues  are  removed,  if  present,  from  between  the  ends 
of  fragments;  the  fragment  ends  are  secured  in  good  apposition; 
callus  formation  is  stimulated  by  the  presence  of  the  graft  at  the 
same  time  that  the  graft  produces  bone  growth  itself;  and  an 
osteogenetic  bridge,  capable  of  conducting  both  blood-vessels 
and  bone  cells  from  one  fragment  to  the  other  is  furnished. 


224 


BONE-(!RAFT    SURfJERV 


Indications  for  Bone -graft  Peg  in  Fracture  of  Neck  of  Femur. 
— This  opcrati(3ii  is  l)elie\ed  to  he  indicated  in  all  ununited 
fractures  of  the  neck  of  the  fenuii-;  in  most  uninipacted  fresh 
fractures,  in  operable  subjects  under   50  years  of  age;  in  all 


Fig.  IGO. — A  roiitgenogram  (kindly  supplied  by  Dr.  B.  C.  Darling)  which  shows 
a  metal  spike  inserted  for  a  fracture  of  the  neck  of  the  femur  in  a  young  person.  The 
result  was  a  failure  and  the  large  amount  of  bone  destruction  about  the  metal  is  clearly 
shown. 

old  fractures  of  the  neck  or  at  the  epiphyseal  cartilage  where 
malunion  has  resulted,  with  the  neck  depressed  in  a  coxa  vara 
relationship  with  the  shaft.  The  bony  deformity  is  corrected  by 
either  a  cuneiform  or  linear  osteotomy,  and  placing  the  limb  in 
full  physiological  abduction  (Whitman). 


INLAY   BONE    GRAFT    IN    FRACTURES 


225 


After  the  operative  correction  of  these  latter  two  conditions 
by  the  usual  cuneiform  osteotomy  Hitzrot  states  that  weight 
bearing  should  be  prohibited  for  at  least  a  year.  The  employ- 
ment of  the  bone-graft  peg  reduces  this  time  by  at  least  6  months. 

Technique  of  the  Author's  Bone-graft  Peg  Operation  for 
Fracture  of  the  Neck  of  Femur. — A  most  careful  iodine  prepara- 


FiG.  161.— R5ntgenogram  of  an  ununited  fracture  of  the  neck  of  the  femur  of  5 
months'  duration  which  has  been  united  by  an  autogenous  tibial  bone-graft  peg.  The 
union  in  this  case  was  immediate  (i.e.,  5  weeks)  and  the  union  has  remained  solid  2 
years  after  operation.  A.  indicates  graft  peg,  from  the  end  of  which  projects  a  mass  of 
new  bone. 

tion  of  a  wide  field  of  operation  should  always  be  carried  out. 
The  pubes  should  be  shaved  on  the  day  before  the  operation  and 
the  preparation  started. 

The  patient  should  be  placed  upon  some  traction  table 
(Hawley)  which  will  allow,  simultaneously,  abduction  and  trac- 
tion. The  point  of  fracture  is  reached  by  an  incision  starting 
from  a  point  a  finger's  breadth  inside  of  the  anterior-superior 


226 


BONE-GRAFT    SURGERY 


spine  and  curved  downward  3  to  5  in.  alonf>;  the  iiuier  border  of 
the  sartorius.  The  inner  border  of  the  muscle  is  exposed  and 
retracted  outward.  The  tendon  of  the  rectus  femoris  is  also 
exposed  and  retracted  outward.  The  ilio-psoas  muscle  is  next 
exposed  and  retracted  inward.  The  point  of  fracture  is 
exposed  and  all  soft  tissue  is  cleared  from  between  the  fractured 
ends,  which  are  curetted  and  freshened. 


Fig.  162. — A  small  wire  nail  which  was  by  mistake  previously  placed  too  high  and 
did  not  engage  the  capital  fragment.  This  case  emphasizes  the  danger  of  misplacing 
a  nail  or  Ijone  graft  and  the  wisdom  of  a  small  hand  drill  for  orientation  as  pointed 
out  by  the  author. 


The  limb  is  now  placed  in  abduction  and  sufficient  traction 
applied  to  bring  the  fragments  into  good  apposition  as  deter- 
mined by  both  sight  and  palpation  through  the  anterior  wound. 
An  incision  2  to  3  in.  long  is  then  made  over  and  just  below  the 
great  trochanter,  which  is  exposed.  With  a  small  hand  drill,  the 
proper  direction  for  the  motor  drill  is  determined  by  trial,  as 


INLAY   BONE    GRAFT    IN    FRACTURES 


227 


shown  by  observation  through  both  wounds.  The  drill  hole 
should  be  situated  in  the  centre  of  the  neck  of  both  distal  and 
proximal  fragments,  and  parallel  to  the  neck.  The  small  hand 
drill  may  have  to  be  reinserted  in  order  to  locate  the  proper  tract 
for  the  motor  drill.  The  motor  drill  should  be  held  ready  by  the 
operator  for  insertion  into  the  tract  of  the  hand  drill  as  it  is 
withdrawn  by  the  assistant.     The  motor  drill,  which  forms  a  hole 


Fig.   163. — Drawing    representing 


patient    on    Hawley    traction    table, 
are  skin  incisions. 


AB   and   CD 


three-eighths  of  an  inch  in  diameter,  is  pushed  through  the  distal 
fragment  until  the  burr  end  of  the  drill  appears  between  the  frag- 
ments, as  seen  through  the  anterior  wound.  Just  as  the  end  of 
the  drill  is  engaging  the  broken  end  of  the  proximal  surface,  a 
reading  on  the  graduated  drill  shaft  is  taken  at  its  entrance  aper- 
ture in  the  great  trochanter,  so  that  by  making  additional  read- 
ings it  can  be  determined  just  how  deep  the  capital  fragment  is 
being  penetrated.  By  studying  the  rontgenogram,  the  length 
of  this  fragment  can  be  very  accurately  determined,  and  hence 


228 


BONE-GRAFT    SURGERY 


the  desired  depth  of  the  drill  hole  obtained,  ^\llell  the  fracture 
has  occurred  near  the  head  and  is  consequently  short,  the  drill 
hole  should  extend  close  to  the  articular  cartilage  of  the  head. 

The  drill  is  disengaged  from  the  motor  and  left  in  place,  to 
avoid  any  possible  displacement  of  the  fragments  while  the  tibial 
graft  is  being  procured. 

The  crest  of  the  lower  portion  of  the  tibia  is  laid  bare,  and  an 
area  of  the  desired  size  and  shape  is  mapped  out  in  the  periosteum 


Fig.  164. — Drawing  to  illustrate  author's  method  of  determining  with  small  hand 
drill  the  proper  situation  and  direction  for  the  motor  drill.  This  hand  drill  is  with- 
drawn as  the  motor  drill  is  inserted.     (See  Fig.  165.) 

with  a  scalpel.  The  desired  length  of  graft  can  be  determined  by 
the  graduated  scale  on  the  motor  drill.  The  cross-section  of  the 
graft  should  be  just  large  enough  to  be  shaped  into  the  peg 
when  the  dowel  shaper  is  used. 

When  the  graft  peg  is  ready,  the  drill  is  withdrawn  from  the 
femur  and  the  peg  inserted.  The  fit  must  be  accurate  because 
the  dowel  cutter  is  the  counterpart  of  the  drill  used.     This  aceu- 


INLAY   BONE    GRAFT    IN    FRACTURES 


229 


Fig.   165. — Insertion  of  motor  drill  into  outer  side  of  great  trochanter  at  point 
determined  by  hand  drill. 


Fig.  160. — When  the  end  of  the  burr  has  reached  the  space  between  the  fragments 
and  is  ready  to  enter  the  capital  fragment,  a  reading  on  the  graduated  shaft  of  the 
burr  is  taken  at  A,  one  is  then  able  to  tell  by  a  study  of  the  rontgenogram  just  how  far 
the  burr  should  penetrate  this  fragment. 


230  BONE-CRAFT    SURGERY 

racy  of  fit  is  very  important.  Too  ti^ht  a  fit  is  undesirable 
):)eraiise  a  pressure  anaemia  of  the  surrounding  cancellous  bone 
would  be  ])roduced.  Too  loose  a  fit,  or  an  irregular  inaccurate 
fit  would  not  produce  good  fixation  or  favor  an  immediate  bony 
union  of  graft  to  the  host  fragments. 

The  deep  fasciae  are  approximated  with  interrupted  sutures 
of  No.  2  chromic  catgut;  the  skin  wound  is  closed  with  continu- 
ous suture  of  No.  1  chromic  catgut. 

The  limb  is  put  up  in  abduction  (Whitman's  position)  in  a 
plaster-of-Paris  spica  extending  from  the  toes  to  the  axilla. 
Three  weeks  after  the  operation,  windows  are  cut  in  the  plaster, 
and  the  wounds  dressed.  The  dressing  should  be  replaced  with 
cotton  for  the  purpose  of  restoring  the  tension  of  the  plaster 
splint  and  retaining  the  fixation.  The  long  spica  should  be 
continued  for  6  weeks,  and  followed  by  a  short  one  for  6  weeks 
longer. 

THE  AUTOGENOUS  BONE   GRAFT  FOR  FRACTURE   OF  THE  PATELLA 

The  usual  treatment  for  fracture  of  the  patella  consists  in 
exposing  the  line  of  fracture  and  uniting  the  fragments  with 
either  absorbable  or  non-absorbable  sutures.  Formerly  metal 
wdre,  such  as  silver  or  phosphor-bronze  wire,  was  used;  but 
recently  the  surgical  pendulum  has  been  swinging  away  from 
non-absorbable  foreign  materials,  and  kangaroo  tendon  or  chro- 
macized  catgut  has  been  more  frequently  chosen.  The  metal 
w^ire,  as  a  rule,  has  either  been  placed  in  a  drill  hole  in  each  frag- 
ment, or  in  such  a  way  as  to  encircle  the  patella.  The  degree  of 
separation  of  the  fragments  depends  largely  upon  the  amount  of 
laceration  of  the  capsule  and  connective  tissue  on  either  side  of 
the  patella.  Muscle  pull  may  interfere  with  the  union  of  the 
patellar  fragments,  however  carefully  the  clots  and  fibrous  frag- 
ments are  cleaned  from  between  the  fragments,  or  whatever 
may  be  the  material  used  to  hold  the  fragments  in  close  apposi- 
tion. Not  infrequently  a  refracture  occurs,  either  immediately 
or  remotely  after  operation,  in  spite  of  every  precaution.     Fi- 


INLAY   BONE    GRAFT    IN    FRACTURES 


231 


brous  union,  with  a  varying  degree  of  separation  of  the  fragments 
and  a  proportional  amount  of  disability  in  the  extremity,  is  a 
more  frequent  unfortunate  result.  To  remedy  either  of  these 
conditions,  Rogers  has  suggested  that  an  autogenous  bone  graft 
be  taken  from  the  crest  of  the  patient's  tibia  and  implanted  on 


Fig.  167. — .-1  is  surgeon  grasping  and  feeding  the  bone  cuts.  Author's  motor- 
driven  lathe.  B  is  nurse  supplying  normal  saline  drip  to  avoid  over-heating  the  graft 
as  fed.  C  illustrates  assistant's  manner  of  holding  the  motor  and  the  lathe  securely 
upon  the  edge  of  instrument  table  while  the  dowel  is  being  shaped. 

the  front  of  the  patella,  to  bridge  the  line  of  fracture.  It  is 
believed  that  this  is  an  important  step  and  that  it  offers  a  very 
trustworthy  means  of  relieving  these  conditions.  It  is  believed, 
however,  that  Rogers'  technique  can  be  much  improved  by  using 
the  author's  inlay  method,  which  he  has  not  only  applied  to 


232 


BONE-GRAFT    SURGERY 


relieve  iibrous  union  and  relraclure,  but  which  lie  offers  as  a 
means  of  securing  immediate  and  solid  bony  union  in  certain 
fresh  fractures  of  tlie  ])atella  (see  Figs.  171  and  172).  In 
other  words,  the  inlay  graft  is  a  reliable  pro})hylaxis  to  fibrous 
union  and  refracture,  as  well  as  a  remedy  for  those  conditions 


Fig.  168. — The  upper  drawing  represents  crest  of  tibia  of  tlie  proper  cross-section 
for  a  hip-fracture  peg.  The  lower  drawing  illustrates  the  peg  and  the  author's  lathe 
cutter  which  was  used  to  shape  it. 

when  already  existing,  without  resorting  to  a  foreign  body. 
Besides  affording  slight  and  imperfect  contact,  the  graft  placed 
on  the  anterior  surface  of   the  patella  fragments  is  liable  to 


Fig.    169. — Drawing  representing  graft  peg  being  driven  home. 

cause  a  pressure  sore  in  the  overlying  skin  because  of  its  super- 
ficial location  fsee  p.  217). 

Technique  of  Inlay  Bone  Graft  for  Fractures  of  the  Patella. 
— Place  tight  tourniquet  on  the  upper  portion  of  the  thigh. 
The  fracture  fragments  are  reached  by  a  U-shaped  flap  with  the 


INLAY   BONE    GRAFT    IN    FRACTURES 


233 


apex  of  its  convexity  over  the  ligamentum  patella  and  its  base 
over  the  condyles  of  the  femur.  Clear  away  carefully  all  blood 
clots  or  fragments  of  fibrous  tissue  from  between  the  fragments, 


/" 


A 


Fig.  170. — AB  is  tibial  bone-yiall  jjck  inserted  6  months  butuie  fur  an  ununited 
fracture  of  5  months'  duration  in  a  man  of  28  years.  There  was  firm  tinion  at  the  end 
of  5  weeks  after  operation.  The  graft  was  placed  lower  than  it  was  intended  but 
did  not  interfere  with  the  result. 


if  it  is  a  fresh  fracture;  or,  in  the  case  of  refracture  or  fibrous 
union,  freshen  the  fragment  ends.  The  fragments  are  approxi- 
mated, and  the  lateral  rents  in  the  fibrous  capsule  are  partially 


234 


BONE-GRAFT   SURGERY 


sutured  at  the  sides  with  interrupted  sutures  of  small  kangaroo 
tendon.  The  central  portion  of  the  anterior  surface  of  the  pat- 
ella is  then  denuded  of  its  periosteum  and  periosseous  tissues 
by  turnin<;-  hack  to  each  side  flaps  on  each  fragment. 


Fig.   171.  Fig.   172. 

Figs.  171  axd  172. — Different  types  of  the  inlay  graft  applied  to  fractures 

of  the  patella. 

An  outline  of  the  bone  to  be  removed — about  Vi  by  3|  in, — is 
made  on  the  anterior  surface  of  the  patella  with  the  point  of  a 
scalpel.  With  the  author's  small  motor  saw,  cuts  are  made  to  a 
depth  of  one-third  of  an  inch  along  the  out- 
lines already  made.  The  fracture  surfaces  of 
the  fragments  are  tilted  forward,  and  wdth 
small  motor  saw  and  narrow,  thin,  sharp  os- 
teotome the  bone  within  the  previously  made 
saw-cuts  is  removed  to  a  depth  of  one-third 
of  an  inch  from  the  anterior  patellar  surface. 

With  the  patellar  fragments  in  good  appo- 
sition, make  careful  measurements  of  the  inlay 
gutter  with  calipers.  Expose  the  antero-inter- 
taii^diJay'VrStYov  ^^^1  surface  of  the  upper  portion  of  the  tibia, 
ununited  fracture  of   where  the  surface  is  broad  and  the  cortex  thin, 

the   patella   with  un- 
avoidable separation    and  by  iiieaiis  of    the    caliper   measurements 

or  wax  model  of  gutter  in  patella,  outline  in  its 

periosteum  the  inlay  graft  required.     The  cortex  in  this  portion 

of  the  tibia  is  of  the  proper  thickness  for  the  graft.     The  inlay  is 

inserted  with  its  periosteal  surface  anterior,  and  the  periosteal 

flaps  of  the  patella  are  pulled  over  it  with  interrupted  chromic 


INLAY   BONE    GRAFT    IN    FRACTURES  235 

catgut  sutures.  The  capsule  rents  are  then  sutured  with  kan- 
garoo tendon  up  to  the  sides  of  the  patella.  The  fragments  are 
still  more  securely  held  together  by  a  figure-of-eight  suture  of 
medium  kangaroo  tendon,  which  is  passed  laterally  through  the 
anterior  portion  of  the  ligamentum  patellae  and  quadriceps 
tendon,  directly  below  and  above  the  fractured  bone,  and  crosses 
in  front  of  the  transplant.  The  skin  incision  is  closed  by  a  con- 
tinuous suture  of  No.  1  chromic  catgut. 

The  limb  is  put  up  in  a  plaster-of-Paris  splint  for  4  weeks. 

This  operation  is  of  the  greatest  advantage  where  there  has 
been  a  fibrous  union  in  an  old  case,  and  a  separation  of  the  frag- 
ments coincident  with  a  shortening  of  the  quadriceps  tendon  and 
muscle;  and  when  the  fragments  cannot  be  brought  into  close 
apposition.  This  space  can  be  spanned  by  a  long  graft,  which 
will  hypertrophy  and  fill  in  to  a  large  degree  (or  entirely)  the 
hiatus  between  the  fragments.     (See  Fig.  173.) 

THE    BONE-GRAFT   PEG   AS    A   TREATMENT   OF   FRACTURE    OF   THE 

OS  CALCIS 

A  fall  in  an  elevator  or  from  a  height,  striking  on  the  plantar 
surface  of  the  foot,  is  very  likely  to  produce  a  fracture  of  one 
of  the  tarsal  bones,  especially  the  os  calcis,  which  is  by  far  the 
most  common  fracture.  These  fractures  of  the  os  calcis  may  be 
classified  into  three  groups:  first,  the  one  in  which  the  fracture 
is  transversely  through  the  central  portion  of  the  bone,  with  a 
displacement  upward  of  the  posterior  fragment  by  the  pull  of 
the  tendo  Achillis;  second,  when  a  portion  of  the  bone  is  torn 
away  by  muscle  pull;  third,  where  there  is  a  fracture  of  the  sus- 
tentaculum tali;  and,  fourth,  where  there  is  comminution,  espe- 
cially in  the  region  where  this  bone  articulates  with  the  posterior 
portion  of  the  astragalus. 

The  type  of  case  in  group  one  only  will  be  considered  in  this 
connection. 

The  chief  consideration  in  the  treatment  of  all  fractures  of 
the  OS  calcis,  and  especially  this  one,  is  to  preserve  or  restore  the 
arch  of  the  foot.  From  the  functional  as  well  as  from  the 
cosmetic  standpoint,  this  is  most  important. 


236  BONE-CRAFT    SURGERY 

Method  of  Reduction  of  Posterior  Fragment. — The  patient  is 
anirsthetized  to  full  iimscular  relaxation;  the  foot  is  brought  into 
full  plantar  flexion  for  the  purpose  of  relaxing  the  tendo  Achillis; 
and  the  heel  is  grasped  firmly  and  an  attempt  is  made  to  pull 
it  downward  into  its  proper  position.  In  order  to  loosen  the 
fragment,  and  break  up  the  impaction  it  may  be  necessary  to 
force  the  heel  laterally  (both  right  and  left).  It  may  then 
be  possible  to  bring  down  the  fragment.  If  this  fails,  as  it  is 
apt  to  do  on  account  of  the  difficulty  of  securing  a  sufficient 
grip  on  the  heel,  Cotton  has  advised  thrusting  a  steel  spindle  (or, 
more  conveniently,  a  small  urethral  sound)  through,  just  in 
front  of  the  tendo  Achillis.  With  this  hold,  there  is  no  difficulty 
in  bringing  the  fragment  down,  if  it  has  not  been  more  than 
a  week  or  two  since  the  fracture.  In  old,  malunited  fractures, 
an  open  cuneiform  osteotomy  on  the  inferior  aspect  of  the  bone 
at  the  point  of  the  fracture  will  be  necessary,  before  attempting 
to  bring  the  fragment  down.  The  incision  is  made  directly 
over  the  inferior  aspect  through  the  plantar  surface  of  the  foot. 
It  is  usually  safer  to  tenotomize  the  tendo  Achillis. 

In  some  instances  internal  fixation  is  advisable,  and  in  these 
cases  the  bone-graft  peg  is  by  all  means  the  most  ideal  agent. 

Author's  Technique  of  Bone -graft  Peg  for  Fracture  of  the 
Os  Calcis. — The  most  satisfactory  incision  is  one  which  passes 
along  the  outer  side  of  the  tendo  Achillis  down  to  the  edge  of 
the  plantar  skin,  and  then  internally  around  the  posterior  part 
of  the  heel.  The  skin  flap  thus  outlined  is  freed  from  the  poste- 
rior end  of  the  os  calcis  and  retracted  inward.  Care  should  be 
exercised  to  keep  close  to  the  bone  in  freeing  up  this  flap,  so  as 
not  to  interfere  with  the  circulation  of  the  flap. 

With  the  posterior  calcaneal  fragment  in  good  position,  a 
hole  about  the  size  of  a  slate  pencil  is  made  longitudinally  in  the 
fragments  with  the  author's  motor  drill.  The  drill  should  be 
started  in  the  centre  of  the  posterior  end  of  the  os  calcis,  driven 
through,  and  then  disengaged  from  the  motor  and  left  in  place 
while  the  peg  is  prepared.  A  strip  of  bone  of  sufficient  size  to 
shape  into  a  dowel  peg  is  then  removed  from  the  crest  of  the 


INLAY   BONE    GRAFT    IN    FRACTURES 


237 


tibia  with  a  motor  saw.  With  the  author's  surgical  lathe,  held 
by  an  assistant  on  the  edge  of  the  instrument  table,  this  strip 
of  bone  is  pushed  into  the  dowelling  instrument,  which  shapes 
it  into  a  round  peg  that  will  just  fit  into  the  drill  hole  in  the  os 
calcis   (see  illustration,   chapter   on  Hip  Fracture).     The  drill 


INFERIOR  ASPECT. 


Fig.  174. — Illustrates  peg  bone  graft  inserted  for  fracture  of  the  os  calcis.      The  tendo 
Achillis  has  been  tenotomized  to  prevent  posterior  fragment  being  displaced  upward. 

is  then  withdrawn  from  the  os  calcis,  the  peg  inserted  and  driven 
home  wdth  blows  of  the  mallet.  The  end  of  the  peg  should  be 
well  counter-sunk  into  the  end  of  the  os  calcis,  so  as  not  to  cause 
pressure  on  the  overlying  skin,  with  danger  of  pressure 
ulceration. 

Fractures  of  the  avulsion  type  from  muscular  pull  may  be 
treated  in  a  similar  way.  In  this  instance,  the  avulsed  frag- 
ment is  replaced  and  pegged  securely  in  position  by  one  or  two 
small  bone-graft  pegs,  a  very  similar  technique  being  used. 


238 


BONE-GKAFT    SURGERY 


Fixation  Dressing.     The  foot  is  put  uj)  in  a  plaster-of-Paris 
dressing,  in  moderate  plantar  flexion.     A  pad  of  gauze  is  placed 


Fig.  175. — Diagram  of  a  fractured  lower  jaw  illustrating  the  inlay  bone  graft  in 
place  imbedded  in  the  gutter  cut  in  both  fragments  by  the  twin  motor  saws.  The 
graft  has  been  procured  from  the  antero-internal  surface  of  the  tibia  cut  by  the  twin 
motor  saws  adjusted  at  the  same  distance  apart  as  when  cutting  the  gutter  in  the  jaw 
fragments.      Note  the  drill  holes  and  that  the  graft  is  fixed  in  place  by  kangaroo  sutures. 


Fig.  176. — Diagram  showing  a  cross-section  of  the  inlay  bone  graft  implanted  for  a 
fracture  of  the  lower  jaw,  and  showing  the  method  of  securing  the  graft  in  position  by 
the  kangaroo-tendon  suture  passed  through  the  drill  holes  and  over  the  graft  holding  it 
securely  in  position. 

smoothly  over  the  superior  and  posterior  part  of  the  heel,  and 
as  the  plaster  sets  it  is  moulded  over  the  heel,  with  traction 


INLAY   BONE    GRAFT    IN    FRACTURES 


239 


downward.  The  full  arch  of  the  foot  is  maintained  by 
ing  the  plaster  well  over  the  dorsal  and  plantar  aspects 
foot.  Union  in  these  cases,  after  this  treatment, 
is  very  prompt.  The  plaster  should  be  cut  and 
transformed  into  a  bivalvular  splint  at  the  end  of 
2  weeks,  when  active  motion  of  the  foot  is  allowed, 
with  gentle  massage.  If  the  case  is  a  fresh  frac- 
ture, weight  bearing  may  be  allowed  in  4  weeks' 
time.  If  it  is  a  case  of  malunion,  this  period  of 
time  should  be  somewhat  lengthened,  in  accord- 
ance with  the  individual  requirements. 


SIMPLE    COMMINUTED   AND   UNUNITED   FRACTURE 
OF   JAW 

Application  of  the  Inlay  Graft. — Fracture  of 
the  lower  jaw  occurs  as  a  rule  in  the  body  of  the 
bone  and  is  usually  associated  with  displacement 
which  persistently  recurs  if  proper  fixation  is  not 
provided.  The  biting  surface  of  the  teeth  is  a 
very  trustworthy  guide  to  the  proper  reduction  of 
the  fracture. 

Fractures  of  this  bone  do  not  as  a  rule  require 
operative  treatment. 


mould- 
of  the 


Fig. 


Maintenance  of  satisfactory  Diagram     iiius- 

tratiag       the 

alignment  can  usually  be  accomplished  either  by  curved  graft  as 

the  interdental  splint  or  by  wiring  the  teeth.  the  antero-inter- 

Fractures  of  the  ramus  are  the  most  difficult  SbLapreparatiry 

to  treat  bv  conservative  means  especially  as  the  *"    cutting    the 

bone  with  the 
motor  saw.  This 
pattern  has  been 
previously  deter- 
mined by  bend- 
ing a  flexible 
probe  into  the 
gutter  on  the 
side  of  the  broken 
jaw. 


interdental  splint  is  inapplicable  in  these  cases. 

If  the  fragments  cannot  be  maintained  in  satis- 
factory alignment  after  a  reasonable  perseverance 
by  conservative  means,  or  if  non-union  has  re- 
sulted, operative  measures  should  be  advised. 

The  inlay  tibial  graft  offers  a  very  satisfactory 
agent  for  the  internal  fixation  of  this  group  of  cases.  Also  for 
comminuted  fractures  with  loss  of  bone  substance  where  it 
should  be  chosen  as  immediate  treatment.     The  bone  graft's 


240 


BONE-GRAFT    SURGERY 


Fig.  178. — Diagram  illustrating  a  fractured  jaw  with  the  gap  spanned  and  the 
fragments  held  by  the  inlay  bone  graft;  also  illustrates  the  manner  of  feeding  such  a 
patient  through  a  tube  introduced  into  the  mouth  from  the  side  opposite  the  fracture. 


Fig.  179. — Diagram  of  a  fractured  lower  jaw  so  badly  shattered  as  to  leave  a  gap 
where  a  proper  position  of  the  remaining  fragments  is  maintained.  This  gap  can  be 
satisfactorily  spanned  and  the  fragments  securely  united  through  the  inlay  method 
with  a  graft  and  gutter  produced  by  the  twin  motor  saws  adjusted  at  the  same  distance 
apart,  producing  an  accurate  fit  of  the  graft  which  is  held  in  position  by  kangaroo- 
tendon  sutures  passed  through  drill  holes  in  jaw  fragments.  This  is  a  frequent  con- 
dition in  the  present  war,  resulting  from  the  trench  warfare. 


INLAY   BONE    GRAFT    IN    FRACTURES  241 

most  important  asset  in  this  type  of  case  is  its  germ-resisting 
property. 

The  inlay  bone  graft  is  placed  into  the  lower  portion  of  the 
outer  surface  of  the  fragments.  The  graft  is  curved  and  shaped 
to  the  contour  of  the  jaw  (see  illustrations  175,  177  and  179). 
Kangaroo  tendon  affords  the  best  fixation  of  the  graft. 

The  support  and  fixation  of  the  fragments  may  be  sufficient 
but  it  is  safer  to  wire  the  teeth  of  the  lower  jaw  to  corresponding 
ones  of  the  upper  jaw.  The  teeth  adjoining  the  site  of  fracture 
should  never  be  selected  for  wiring  as  they  are  likely  to  become 
loosened. 

The  post-operative  dressing  should  consist  of  leather  chin 
piece  or  a  four-tail  bandage. 

Especial  directions  should  be  given  that  the  patient  take 
liquid  diet  and  keep  the  mouth  clean  as  possible  with  mouth 
washes. 

Comminuted  compound  fracture  of  the  jaw,  due  to  modern 
rifle-bullet  and  trench  warfare,  is  one  of  the  most  frequent 
injuries  in  the  present  European  war.  It  has  been  reported 
that  500  soldiers  with  comminuted  gunshot  fractures  of  the 
lower  jaw  have  been  segregated  in  one  hospital  in  Germany. 


16 


CHAPTER  V 

OPERATIVE  METHODS  FOR  REMODELLING  OR  ANKYLOSING 

THE  HIP-JOINT 

THE  BONE-GRAFT  WEDGE  APPLIED  IN  TREATMENT  OF  ACQUIRED 
DISLOCATION  AND  RELAPSING  CONGENITAL  DISLOCATION 
OF  THE  HIP 

Acquired  Dislocation  of  the  Hip,  such  as  paralytic  luxation, 
was  described  as  early  as  1877  by  Reclus,  since  which  time  a 
number  of  writers  have  set  forth  the  nature,  aetiology  and  treat- 
ment of  the  deformity;  but  up  to  the  present  time  no  unanimity 
of  opinion  has  been  reached  in  regard  to  these  points. 

There  are  two  kinds  of  paralytic  luxation  of  the  hip:  The 
iliac  luxation,  from  paralysis  of  the  abductors  and  external 
rotators;  and  the  pubic  luxation  from  the  paralysis  of  the  adduc- 
tors and  internal  rotators.  Dislocations  of  this  nature  are  not 
infrequent,  but  are  usually  diagnosed  by  associated  contractures, 
adduction  in  the  case  of  posterior  luxation,  and  abduction  of  the 
thigh  with  flexion  in  the  pubic  luxations.  The  iliac  dislocation 
is  believed  to  be  the  one  more  frequently  met  with.  The  pubic 
displacement  is  difficult  to  confirm  by  rontgenogram,  because 
of  the  obscurity  rendered  by  the  neighboring  bony  parts, 
where-as  the  iliac  luxation  is  readily  revealed  by  the  rontgeno- 
gram. Clinical  examination  is  rendered  somewhat  difficult 
by  the  atrophy  of  the  muscles  and  altered  direction  and  shape 
of  the  femoral  neck,  as  well  as  by  the  presence  of  contractures. 

These  luxations  may  be  due  to  muscle  contraction,  or  ex- 
treme paralysis  of  hip  muscles  and  a  stretching  of  the  unsup- 
ported capsule  in  cases  unable  to  walk,  but  they  also  occur  from 
static  causes,  even  where  paralysis  is  slight  and  there  is  an  other- 
wise perfectly  useful  limb.  Among  the  important  physical  signs 
indicating  luxation  are  adduction  and  abduction  contractures, 
with  or  without  flexion  of  the  thigh.     An  iliac  luxation  lordosis  is 

242 


REMODELLING    OR    ANKYLOSING    HIP-JOINT  243 

to  be  looked  for,  and  if  the  luxation  is  unilateral  a  tilting  of  the 
pelvis  out  of  proportion  to  the  atrophy  and  shortening  of  the  leg, 
due  directlj^  to  the  paralysis,  is  appreciable. 

The  use  of  external  appliances  in  treating  these  cases  beyond 
the  immediate  correction  of  deformity  is  unsatisfactory,  and  in 
order  to  control  these  redislocating  paralytic  hips  the  author  has 
applied  the  autogenous  bone  wedge  to  deepen  the  overhanging 
rim  of  the  acetabulum  which,  in  conjunction  with  reefing  the 
ballooned  portion  of  the  joint  capsule,  furnishes  a  stable  and 
satisfactory  hip-joint. 

The  indications  for  an  open  operation  in  paralytic  dislocations 
of  the  hip  are  the  inability  to  replace  the  head  of  the  femur, 
owing  to  contractures  of  the  soft  parts;  faulty  displacement  of 
joint  structures;  or  such  relaxation  as  to  permit  of  redislocation 
after   repeated   reductions. 

Contractured  structures  are  thoroughly  stretched  and  the 
dislocation  reduced,  if  possible,  by  the  closed  method.  Failing 
in  this,  or  succeeding  only  to  have  a  redisplacement  occur 
subsequently,  the  open  method  devised  by  the  author  can  be 
resorted  to  when  it  is  found  that  the  redisplacement  is  due  to  a 
relaxed  capsule  and  a  shallow  acetabulum.  The  difficulty  in 
paralytic  dislocations  of  the  hip,  as  a  rule,  is  not  the  reducing  of 
the  dislocation  but  the  retaining  of  the  hip  in  position  after  the 
reduction.  The  wearing  away  or  flattening  of  the  rim  of  the 
acetabulum  results  from  the  head  slipping  in  and  out  repeatedly. 
In  some  cases  this  occurs  with  every  step  the  child  takes. 

This  open  method  for  retention  of  the  femoral  head  applies 
both  to  paralytic  and  congenital  dislocations.  In  congenital 
dislocations,  it  has  been  applied  only  in  those  cases  where  the 
acetabulum  is  shallow  and  the  hip  will  not  stay  in  place  after  a 
reasonable  trial  by  the  bloodless  method.  An  open  operation 
for  the  reduction  of  hip  dislocation  must  be  considered  a  major 
operation  and  should  be  undertaken  under  strictest  aseptic 
precautions.  The  result  to  be  expected  is  a  stable  joint  with  the 
widest  range  of  motion,  without  pain,  and  with  the  least  short- 
ening possible. 


244  BONE-GRAFT    SURGERY 

In  many  cases  of  hip  dislocation  the  acctabiikini  is  found  to  be 
too  shallow  and  with  a  superior  rim  insufficient  to  retain  the 
femoral  head.  To  obviate  this  defect,  Hoffa,  in  1890,  did  his 
first  successful  operation,  which  consisted  chiefly  in  deepening 
the  acetabulum  by  scooping  out  the  contained  fat,  articular 
cartilage  and  bone,  to  furnish  an  adequate  concavity  to  receive 
and  hold  the  head  of  the  fenuir.  By  this  method  he  was  en- 
abled to  produce  a  stable  joint,  but  in  many  instances  with 
little  or  no  motion  without  pain,  and  in  many  others  pro- 
ducing a  stiff  hip  with  a  varying  amount  of  shortening  of 
the  leg,  depending  upon  the  amount  of  excavation  made  in 
the  superior  portion  of  the  acetabulum  to  receive  the  head 
of  the  femur.  In  cases  where  motion  seemed  free  shortly  after 
the  operation,  a  later  examination  showed  it  to  be  slight,  if  any 
at  all,  and  at  a  still  later  period  there  was  evidence  of  a  pro- 
liferative arthritis. 

The  author's  method,  which  has  been  performed  successfully 
in  a  number  of  instances,  obviates  the  above-mentioned  disad- 
vantages and  produces  a  stable  joint  with  full  and  free  motion 
and  without  pain  or  shortening.  The  most  important  feature  is 
that  it  preserves  the  entire  acetabulum  and  joint  cartilage,  thus 
guarding  against  any  later  joint  change.  It  may  be  described 
as  the  bone-wedge  graft  remodelling  operation  for  paralytic  and 
congenital  dislocation  of  the  hip. 

The  important  points  of  advantage  which  it  possesses  over 
the  Hoffa  open  operation  are: 

1.  It  is  an  operation  of  less  magnitude,  producing  less  shock 
and  mutilation  of  the  anatomical  joint  structures. 

2.  There  is  a  preservation  of  the  synovial  membrane  and 
hyaline  cartilage  of  the  joint  as  well  as  the  ligamentum  teres, 
which  remains  undisturbed  if  it  is  present. 

3.  The  operation  is  performed  without  the  disarticulation 
or  extensive  traumatization  of  the  head  of  the  femur,  a  most 
important  factor  in  avoiding  shock  and  subsequent  traumatic 
degenerative  change  in  the  joint. 

4.  There  is  no  shortening  of  the  limb  produced  by  the  opera- 


REMODELLING    OR    ANKYLOSING    HIP-JOINT 


245 


tion,  as  no  portion  of  the  existing   articular   structures  is   re- 
moved or  scooped  out,  as  in  the  Hoffa  operation. 

5.  There  is  a  restoration  of  joint  stability  and  a  reinforcing 
of  the  joint  structures  present,  and  an  actual  addition  to  the 
joint  anatomy  by  the  insertion  of  these  bone  grafts,  to  be  de- 
scribed. 

6.  The  author's  method  minimizes  any  possibility  of  limited 
motion  of  the  remodelled  joint,  or  subsequent  production  of 
osteoarthritis  to  limit  motion  or  produce  painful  motion. 


Fig.   180. — Heavy  line  indicates  lateral  skin  incision  when  tip  of  trochanter  is 
turned  up  for  an  approach  to  the  hip-joint. 


THE  BONE-GRAFT  WEDGE  IN  THE  TREATMENT  OF  CONGENITAL  AND 
ACQUIRED  DISLOCATION  OF  THE  HIP 

Author's  Technique. — The  technique  of  the  operation  is  as 
follows:  All  existing  contractures  having  been  overcome  by 
forcible  manipulation  or  open  division,  and  the  dislocation  made 
easily  reducible  by  weight  and  pulley  traction  or  manipulation 
under  ether,  an  incision  is  made  from  the  anterior-superior 
spine  of  the  ilium  to  the  great  trochanter,  then  backward  1  to 
2  in.  in  the  direction  of  the  ischial  tuberosity;  the  skin  and  sub- 
cutaneous structures  are  dissected  back  and  the  trochanter 
exposed;  the  tip  of  the  trochanter  is  developed,  with  its  muscle 
attachments,  and  sawed  off  with  the  motor  saw.  This  tro- 
chanter tip,  with  its  attached  muscles,  is  turned  upward,  giving 
a  free  exposure  of  the  superior  and  posterior  portions  of  the 
capsule  of  the  joint,  together  with  its  attached  portion  of  the 
superior  and  posterior  acetabular  rim ;  this  portion  of  the  capsule 


246  BONE-fJRAFT    SURGERY 

is  seen  and  felt  to  be  lax  if  the  head  is  in  the  acetabulum,  and 
if  the  head  of  the  femur  is  disarticulated  it  distends  the  capsule 
by  pressure  from  beneatli  and  further  displacement  of  tlie  head 
is  resisted.  Upon  manipulation  of  the  femur,  the  head  is  readily 
felt  as  a  rounded  hard  surface  slippino;  about  beneath  the  cap- 
sule. 

The  amount  of  deficiency  of  the  acetabular  rim  can  be  very 
easily  determined  at  this  stage  by  direct  palpation,  and  manipu- 
lation of  the  thigh,  and  also  the  amount  of  laxity  of  this  portion 
of  the  capsule.  Above  the  capsule  attachment  to  the  acetabular 
rim  the  bone  surface  is  cleared  of  soft  tissue,  and  with  a  narrow 
thin  osteotome  the  bone  is  incised  just  above  the  insertion  of  the 
capsule  in  a  semicircular  line  in  this  posterior-superior-anterior 
surface,  to  conform  to  the  natural  curvature  of  the  superior 
rim  of  the  acetabulum.  This  semicircular  bone  incision  pro- 
duces a  strip  of  the  superior  curved  bone  margin  of  the  acetabu- 
lum with  its  attached  and  undisturbed  capsule  segment.  This 
curved  acetabular  bone  segment  is  pried  outward  and  downward 
with  the  osteotome  to  deepen  the  acetabulum  sufficiently  to  offer 
an  obstruction  to  displacement  of  the  femoral  head,  i.e.,  this 
superior  curved  rim  of  the  acetabulum  is  made  to  overhang 
and  more  securely  grasp  the  head  of  the  femur  when  placed 
in  its  socket  (see  illustration  187).  The  prying  downward 
and  outward  of  this  curved  superior  bony  rim  segment  pro- 
duces still  more  laxity  and  wrinkling  of  the  attached  portion 
of  the  capsular  ligament.  The  slack  is  taken  up  by  reefing 
this  portion  of  the  capsule  by  a  row  of  mattress  sutures  of 
kangaroo  tendon  placed  at  right  angles  to  the  long  axis  of  the 
neck  of  the  femur.  The  stitches  are  so  placed  as  to  make  the 
reef  of  the  capsule  lie  equidistant  from  the  two  ends  of  the 
capsular  bone  insertions.  This  reefing  avoids  entering  the 
joint,  takes  up  the  slack  of  the  capsule,  and  at  the  same  time 
holds  the  new-formed  or  placed  acetabular  rim  in  position. 

To  fill  in  the  bone  gap  produced  by  the  prying  downward 
and  outward  of  this  curved  bone  rim  segment,  and  to  further 
secure  the  permanent  fixation  of  this  new-formed  acetabular 


REMODELLING    OR    ANKYLOSING    HIP-JOINT 


247 


rim,  a  segment  of  bone  having  a  triangular  cross-section  is  re- 
moved from  the  crest  of  the  tibia,  long  enough  when  cut  into 
three  or  more  portions  to  fill  in  this  gutter.  Before  disengaging 
this  graft  from  the  tibia,  six  drill  holes  are  made  in  this  bone 
segment,  so  placed  that  when  this  long  graft  is  cut  into  three 
portions  prior  to  being  placed  in  position  there  are  two  holes  in 
each  portion.  The  illustration  shows  the  direction  in  which 
the  saw-cut  is  made  in  the  crest  of  the  tibia  to  produce  the 
wedge  graft. 


Fig.  181. — Method  of  using  motor  to  incise  tip  of  great  trochanter  for  the  purpose 
of  exposing  the  hip-joint  by  turning  of  trochanter  with  the  muscles,  attached,  upward. 
A  chisel  or  gigli  saw  can  be  used  for  this  purpose. 

Bone  pegs,  if  used,  are  made  from  additional  strips  of  bone 
obtained  from  the  tibia  just  above  where  the  bone  graft  is 
obtained,  and  these  are  turned  to  fit  the  previously  formed  drill 
holes  in  the  graft  segments.  This  is  quickly  accomplished  in 
the  motor-driven  surgical  lathe.  The  long  wedge  graft  is  re- 
moved from  the  tibia  and  cut  into  the  three  mentioned  portions, 
which  are  placed  in  position  and  pegged  to  the  pelvis.  As  a 
rule,  the  cancellous  bone  structure  of  this  portion  of  the  pelvis 
is  satisfactorily  penetrated  by  the  cortical  bone  pegs  without 


248 


BONE-GRAFT    SURGERY 


further  drilliii^.  These  pegs  shoukl  extend  through  the  graft 
uiid  into  the  pelvic  bone  for  one-half  to  three-quarters  of  an  inch. 
In  certain  cases  it  has  been  found  that  these  bone  pegs  to  hold 
the  graft  in  position  are  unnecessary,  and  tliat  sufficient  fixation 
is  produced  by  drawing  the  soft  tissues  over  the  graft  with 
kangaroo  sutures. 

The  tip  of  the  trochanter  with  its  attached  nuiscle  insertions 
is  returned  to  its  normal  position  and  sutured  with  kangaroo 


Fig.    182. — Congenital  or  paralytic  dislocation  of  the   hip  with  the  head  of  the 
femur  stretching  the  capsule. 


tendon  through  the  periosseous  structures.  The  skin  is  closed 
with  continuous  sutures  of  No.  1  chromic  catgut,  without  drain- 
age. The  limb  is  placed  in  an  abducted  position  and  fixed  by 
a  long  plaster-of-Paris  spica  reaching  from  the  thorax  to  the  toes, 
which  remains  on  for  6  weeks,  and  is  then  replaced  by  a  short 
spica  for  an  additional  6  weeks,  when  the  cast  is  removed 
and  passive  and  active  exercises  are  instituted,  together  with 
massage  and  guarded  functional  use  of  the  limb. 


REMODELLING    OR    ANKYLOSING    HIP-JOINT  249 

OPERATIVE  TREATMENT   IN  SELECTED  CASES  OF  OSTEOARTHRITIS, 

ADULT  TUBERCULOUS   HIP-JOINT  DISEASE,  AND  CERTAIN 

TRAUMATIC  AND  DANGLE  (PARALYTIC)  HIPS 

It  has  long  been  a  well-known  fact  that  a  large  number  of 
progressive  and  advanced  cases  of  arthritis  deformans  (osteo- 
arthritis) of  the  hip,  with  the  accompanying  deformity  and 
disability,  fail  to  respond  to  the  conventional  methods  of 
systemic,  hygienic,  rest,  or  brace  treatment,  and  progress  toward 


Fig.  183. — Represents  the  head  of  the  femur  reduced  and  in  the  acetabulum.  The 
tip  of  the  great  trochanter  is  turned  upward  with  its  attached  muscles.  The  superior 
and  posterior  portions  of  the  capsule  are  much  ballooned.  The  dotted  line  indicates 
the  bone  section  which  is  carried  one-half  the  waj'  around  the  rim  of  the  acetabulum 
on  its  anterior-superior  and  posterior  aspects.      (See  Fig.  184  and  186.) 

complete  invalidism.  This  class  of  cases  is  met  with  in  adult 
life,  and  the  length  of  time  required  by  the  treatment  heretofore 
employed  cannot  be  satisfactorily  undertaken  by  the  working 
man  with  a  family  dependent  upon  him,  even  though  the  chances 
are  good  for  an  ultimate  recovery. 

With  marked  anatomical  and  pathological  changes  present, 


250 


B()NE-(iRAFT    SURGERY 


such  as  the  wearing  away  of  the  femoral  head  and  acetabulum, 
eburnation,  osteophytes,  and  the  associated  flexion  and  adduction 
deformity,  satisfactory  results  can  rarely  be  expected  from  ex- 
pectant treatment.  (See  Fig.  188.)  A  resection  of  the  upper 
extremity  of  the  femur  has  l)een  practised  by  Hoffa  and  others, 
with  very  unsatisfactory  results.  Hoffa  was  one  of  the  last  to 
discard  complete  excision.  Forcible  manipulation  under  ether 
has  produced  disastrous  results  in  both  the  hypertrophic  and  the 
atrophic  types.     In  the  hypertrophic  type,  forcible  manipula- 


Fig.  184. — Author's  technique  of  operation  for  paralytic  and  congenital  dislocation 
of  the  hip,  illustrating  the  division  of  the  tip  of  the  great  trochanter  with  its  attached 
muscles  lifted  upward  to  expose  the  joint  capsule.  The  supra-acetabula  curved  bone 
incision  and  reef  sutures  in  the  capsule  are  shown  after  depressing  the  curved  bony 
superior  rim  of  the  acetabulum. 

tions  of  the  parts  produces  further  hypertrophy  in  many  in- 
stances, more  pain,  and  ultimate  deformity  by  the  traumatization 
of  the  joint  structures;  and  in  the  atrophic  condition,  on  account 
of  osseous  rarefaction,  further  damage  is  likely  to  occur  from  the 
crushing  of  this  rarefied  bone.  When  this  disorganizing  condi- 
tion of  the  hip-joint  exists,  with  its  accompanying  adduction  and 
flexion,  with  firm  muscular  contractures  and  a  progressive  bony 
obstructive  ankylosis  with  the  thigh  in  this  faulty  position,  it 
has  seemed  best  to  aim  for  an  immediate  firm  ankylosis  by 
means  of  an  ojjeration  (see  Albee:    The  Journal  of  the  American 


REMODELLING    OR    ANKYLOSING    HIP-JOINT 


251 


Medical  Association,  June,  1908),  at  which  time  the  limb  is 
placed  in  a  position  of  shght  over-correction  to  compensate  for 
the  existing  practical  shortening,  there  being  but  little  further 
actual  bone  shortening  produced  by  the  operation. 


Fig.  185. — The  method  of  the  removal  of  the  bone  from  the  crest  of  the  tibia,  to  be 
divided  into  segments  with  the  motor  saw  and  used  as  bone-graft  wedges  in  paralytic 
and  congenital  dislocation  of  the  hip. 


The  author  has  operated  by  the  following  method  in  50 
cases,  the  patients  ranging  from  22  to  67  years  of  age,  and  the 
time  since  the  first  cases  were  so  treated  has  been  over  7  years. 
Furthermore,  to  the  author's  knowledge,  the  operation  has  been 
performed  by  a  number  of  other  surgeons,  all  of  whom  have 
reported  satisfactory  results. 


252 


BONE-GRAFT    SI^RCiERY 


Technique   of   the  Author's  Arthrodesis   Operation  of  the 

Hip. — The  hip-joint  is  reached  in  tliiii  subjects  l)y  an  ante- 
rior incision,  5  in.  long,  through  the  skin  and  subcutaneous 
tissues,  starting  from  just  below  and  inside  of  the  anterior- 
superior  spine  of  the  ilium  and  extending  downward.  The 
sartorius  muscle  is  retracted  outward;  the  deeper  muscles  and 
structures  are  separated  by  blunt  dissection  and  the  iliacus  and 
the  rectus  femoris  muscles  are  retracted  inward.  A  part  of  any 
group  of  osteophytes  about  the  acetabulum  is  turned  upward 
with    the    soft    tissues    adherent    to    them,  since    it    is    con- 


FiG.  186. — Technique  of  operation  for  paralytic  and  congenital  dislocation  of  the 
hip,  illustrating  four  autogenous  bone-graft  wedges.  B  held  in  position  in  the  supra- 
acetabula  curved  bone  gutter  by  autogenous  bone  dowel  pegs  inserted  through  drill 
holes  extending  through  each  graft  wedge  into  the  adjacent  bony  wall  of  the  pelvis. 
A  is  tip  of  trochanter  turned  up  with  its  attached  muscles.  Four  wedge  grafts  are 
shown  in  this  drawing.     Two  or  three  are  often  sufficient. 

sidered  advisable  to  preserve  as  many  as  feasible  on  ac- 
count of  their  bone-producing  possibilities.  In  a  thick  muscu- 
lar thigh  where  there  is  much  bony  outgrowth  overhanging 
the  joint,  it  requires  some  care  to  locate  the  joint  accu- 
rately. The  capsule  is  opened.  With  the  head  of  the  femur 
in  situ,  approximately  one-third  of  its  upper  hemisphere  is  re- 
moved with  a  long  osteotome  or  chisel — five-eighths  of  an  inch 
in  width — in  a  plane  nearly  parallel  with  the  long  axis  of  the 
neck  of  the  femur.     With  the  same  instrument  and  a  strong 


EEMODELLING    OE    ANKYLOSING    HIP-JOINT  253 

curette  with  a  cross  handle,  the  acetabulum  is  transformed 
into  a  flat-surfaced  roof  against  which  the  flat  surface  of  the 
head  is  finally  brought  into  firm  contact  by  abduction  of  the 
thigh.  If  the  adductor  muscles  prevent  the  required  amount 
of  abduction,  an  open  division  of  these  muscles  and  tendons  is 
made  to  permit  the  leg  to  be  brought  into  the  desired  position. 
The  acetabular  and  femoral  head  surfaces  are  brought  into 
contact  by  simply  abducting  the  thigh.  The  capsule  and  soft 
tissues  are  sutured. 


Fig.  187. — Antero-posterior  view  of  remodelled  hip-joint  with  wedge  bone  graft 
pinned  in  position  depressing  the  superior  rim  of  the  acetabulum,  the  superior  portion 
of  the  capsule  reefed,  and  the  tip  of  trochanter  with  its  attached  muscles  restored  to  its 
position  and  fastened  with  kangaroo  tendon. 

Access  to  the  joint  is  much  facilitated  by  a  position  of 
extreme  adduction  of  the  limb.  For  the  purpose  of  orientation, 
an  assistant  is  kept  in  constant  readiness  to  rotate  the  femur 
while  the  operation  is  in  progress.  The  bone  is  removed  in  such 
a  wa}^  that  the  flat  pelvic  surface  is  tilted  up  mesially  somewhat, 
in  order  to  produce  a  locking  of  the  parts  and  to  prevent  any 
possibility  of  dislocation  from  weight-bearing. 


254  BONE-GRAFT    SUIIGEHY 

In  very  stout  patients,  with  thick  thigh  muscles,  the  tech- 
nique of  lateral  approach  to  the  hip-joint  described  by  Brackett 
may  be  used  to  advantage  as  follows: 

The  hip-joint  is  reached  by  an  incision  fi'om  the  anterior- 
superior  spine,  obliquely  downward  and  outward  to  the  middle 
of  the  outer  side  of  the  trochanter,  and  then  downward  2  in. 
in  the  line  of  the  femur.     At  the  point  where  the  oblique  por- 


FiG.  188. — Advanced  arthritis  deformans  (osteoarthritis)  of  the  hip  in  which  the 
acetabulum  has  become  filled  with  new  bone  and  the  head  of  the  femur  dislocated. 
(From  specimen  in  the  College  of  Physicians  and  Surgeons.) 

tion  joins  the  vertical,  just  over  the  trochanter,  an  incision  is 
made  directly  backward,  2  to  3  in.  in  length,  down  to  the  fascial 
portion  of  the  gluteus  maximus.  After  separating  the  tensor 
fascia  femoris  and  the  gluteus  medius,  the  line  of  separation  is 
extended  downward  along  the  line  of  the  original  incision, 
through  the  fascia  lata  to  the  femur,  freeing  the  attachment  of 
the  muscles  (vastus  externus)  from  the  outer  and  upper  surfaces 


REMODELLING    OR    ANKYLOSING    HIP-JOINT 


255 


Fig.  189. — The  broken  lines  indicate  the  amount  of  bone  to  be  removed.  It  is 
removed  from  the  head  and  the  acetabulum  in  different  planes  in  order  to  secure  the 
desired  abduction  of  the  thigh,  when  the  freshened  bone  surfaces  are  brought  together. 

Apposition  of  the  freshened  bone  surfaces  after  the  removal  of  the  bone  from  the  head 
and  the  acetabulum,  and  the  femur  placed  in  slight  abduction.  The  blackened  area 
indicates  where  the  cartilage  is  removed  when  the  femur  is  strongly  rotated  outward 
for  that  purpose. 

All  the  small  fragments  of  bone  are  not  removed  with  as  much  care  as  formerly. 
They  are  left  in  or  selected  ones  replaced  on  account  of  their  osteogenetic  activity. 


Fig.  190. — Author's  arthrodesis  of  the  hip-joint  showing  the  incised  flattened 
superior  surface  of  the  head  of  the  femur  in  apposition  with  the  incised  flattened  superior 
surface  of  the  acetabulum,  with  the  parts  of  osteophytes  and  small  bone  grafts  placed 
along  the  contacted  bone  area.     Lateral  view. 


256  BONE-GRAFT    SURGERY 

of  the  fciiuir.  The  fascial  expansion  of  the  gluteus  maxinius 
is  then  cut  through  along  the  line  of  the  posterior  part  of  the 
original  incision,  and  the  outer  part  of  the  trochanter  exposed. 

This  gluteal  flap  is  turned  backward,  and  the  outer  and  upper 
surfaces  of  the  trochanter  are  fully  exposed.  The  upper  portion 
of  the  trochanter  is  then  chiselled  off  by  cutting  directly  back- 
ward with  a  narrow  osteotome,  on  a  curved  line  beginning  on 
the  outer  surface  of  the  trochanter,  II2  iii-  below  the  tip,  and 
cutting  inward  for  j^  in.,  then  curving  upward  to  the  fossa 
at  the  junction  of  the  upper  part  of  the  neck  and  the  trochan- 
ter. This  removes  the  outer  portion  and  tip  of  the  trochanter, 
and  with  it  the  attachments  of  the  gluteus  medius,  gluteus  mini- 
mus, and  pyriformis.  The  motor  or  Gigli  saw  can  be  used.  Care 
should  be  taken  in  the  removal  of  this  piece  not  to  encroach  on 
the  neck,  or  the  bone  will  be  weakened  at  this  angle.  The  por- 
tion of  bone  removed,  with  the  muscles  attached,  is  deflected 
backward  and  upward  enough  to  uncover  the  upper  part  of  the 
femoral  neck,  and  the  muscular  covering  of  the  anterior  fibres 
of  the  gluteus  medius  and  minimus  are  easily  separated  from 
the  region  above  the  acetabular  rim.  The  incision  through  the 
trochanter  just  borders  on  or  opens  the  outer  edge  of  the  capsule 
on  the  upper  surface  of  the  neck,  and  the  incision  of  the  capsule 
opens  directly  into  the  cavity  of  the  joint.  The  capsule  may  be 
split  along  its  upper  surface,  parallel  to  the  neck,  and  near  to  its 
acetabular  insertion  and  cut  transversely  on  each  side,  which 
opens  the  view  of  the  edge  of  the  head  and  rim  of  the  upper 
half  of  the  acetabulum. 

The  leg  is  finally  put  in  a  long  spica  extending  from  the 
axilla  to  the  toes,  in  strong  abduction  and  10  degrees  of  flexion. 
If  the  convalescence  is  uneventful,  the  patient  is  usually  walk- 
ing in  5  weeks,  with  the  aid  of  crutches.  A  short  spica  is  then 
substituted  for  the  long  one  for  a  period  of  7  weeks  longer. 

It  has  been  found  in  the  later  cases  that  to  remove  the  over- 
hanging edge  of  the  acetabulum  first  renders  the  removal  of  the 
upper  surface  of  the  head  of  the  femur  easier.  If  the  upper 
third  of  the  femoral  head  to  be  removed  is  cut  into  segments 


REMODELLING    OR    ANKYLOSING    HIP-JOINT 


257 


by  a  thin  osteotome,  and  by  cutting  at  right  angles  to  the  first 
bone  incision,  the  removal  of  this  portion  of  the  head  is  facili- 
tated. After  this  segment  of  the  head  is  removed,  all  the  ac- 
cessible articular  cartilage  is  sliced  from  the  anterior  portion 
of  the  head,  brought  into  view  by  strongly  rotating  the  femur 
outward.     The  cartilage  is  also  removed  from  the  contiguous 


Fig.  191. — Bony  union  after  author's  arthrodesis  for  osteoarthritis  of  the  hip  with 
relief  of  all  symptoms.  The  arrow  indicates  small  bone  grafts  placed  about  rim  of 
joint. 


portion  of  the  acetabulum  with  a  thin  osteotome.  In  operating 
upon  stout  persons,  one  is  forced  to  depend  very  largely  upon  the 
sense  of  touch  in  this  removal  of  bone  and  cartilage. 

One  precaution  should  be  emphasized,  and  that  is  the  re- 
moval of  the  overhanging  shell  of  osteophytes  before  incising 
the  femoral  head.     The  reason  for  this  is  to  avoid  being  misled 

17 


258 


BONE-GRAFT    SURGERY 


and  makiiifi;  the  capital  incision  too  low,  and  thus  removing  a 
larger  segment  than  is  desirable.  The  removal  of  one-third  of  the 
head  furnishes  as  extensive  afresh  bone  surface  as  can  be  obtained 
for  ankylosis,  and  at  the  same  time  the  hip  is  not  loosened  nor  the 
limb  shortened  to  any  material  degree.  The  tendency  always 
is  to  regard  the  hip-joint  as  being  situated  lower  than  it 
actually  is. 


Fig.  192. — A  case  of  osteoarthritis  with  flattening  of  the  head  and  osteophytes  at 
A  and  B.  A  bony  ankylosis  was  produced  by  author's  technique  of  arthrodesis  and 
all  symptoms  were  immediately  relieved.  , 

Illustrative  cases  of  osteoarthritis  of  the  hip  operated  by  this 
method : 

Case  I. — In  October,  1906,  M.  N.,  a  policeman  59  years  of 
age,  was  referred  to  the  author  by  Dr.  J.  L.  Moriarty  of  Water- 
bury,  Conn.     An  examination  revealed  arthritis  deformans  of 


REMODELLING    OR    ANKYLOSING    HIP-JOINT  259 

the  right  hip.  Hygienic  and  brace  treatment  were  recom- 
mended and  explained.  It  was  decHned  on  the  ground  that  the 
time  required  was  so  long  and  that  the  possible  results  were  too 
uncertain  for  a  working  man  with  a  dependent  family.  The 
following  May  (1907)  this  patient  returned  to  the  writer  and 
begged  that  something  be  done  for  him.  He  was  admitted  to  the 
New  York  Post-Graduate  Hospital  May  14,  1907,  with  the 
following  history:  Policeman  for  the  past  25  years.  Three 
years  before,  he  first  began  to  notice  pain  and  stiffness  in  the 
right  thigh  and  hip.  Soon  after  this  he  went  to  Mount  Clemens, 
where  he  took  a  considerable  number  of  baths.  His  general 
health  was  improved,  but  the  pain  and  disability  continued  as 
before.  Two  years  ago  he  w^as  examined  by  a  physician  and 
was  told  that  his  right  hip  was  dislocated  and  that  the  right 
leg  was  2  in.  shorter  than  the  left.  The  symptoms  became 
so  severe  that,  3  months  after  consulting  the  writer  in  De- 
cember, 1907,  patient  went  to  New  Haven  and  submitted  to  an 
operation,  the  nature  of  which  could  not  be  ascertained.  Lame- 
ness, stiffness,  and  pain  continued  unabated. 

The  physical  examination  revealed  a  muscular  man  with  a 
pale  and  careworn  countenance  and  a  markedly  shortened  right 
limb.  His  right  shoe  was  built  up  with  a  cork  extension  2^^ 
in.  thick.  The  limb  was  much  atrophied  and  was  markedly 
adducted  and  flexed.  A  long  linear  scar  was  noted  over  the 
right  trochanter.  The  actual  bony  shortening  of  the  right 
limb  was  ji  in.;  the  practical  shortening  was  23^  in.  The 
motion  was  very  slight,  except  for  the  presence  of  about  one- 
half  the  normal  amount  of  flexion.  Attempts  at  passive  motion 
were  painful.  There  was  some  muscular  spasm.  A  rontgeno- 
gram  showed  the  head  of  the  femur  much  worn  away  and 
flattened,  with  many  bony  outgrowths  about  the  rim  of  the 
acetabulum. 

In  view  of  the  disorganization  of  the  joint,  the  marked  ad- 
duction and  flexion,  with  firm  muscular  contractures,  and  the 
progression  toward  bony  obstructive  ankylosis  with  the  leg  in 
the  above-mentioned  faulty  position,  in  a  person  so  large  and 


260  BONE-GEAFT    SURGERY 

muscular,  it  seemed  best  to  aim  for  an  immediate  firm  ankylosis 
by  means  of  an  operation,  and  in  order  to  compensate  for  the 
existing  practical  shortening,  to  place  the  limb  in  a  position  of 
slight  over-correction  of  the  deformity.  Therefore,  the  operative 
indications  were  to  dcA-ise  a  procedure  which  would  fulfil  the 
above  requirements  and  at  the  same  time  produce  as  little 
bony  shortening  as  possible. 

Access  to  the  joint  was  much  facilitated  by  a  position  of 
extreme  adduction  of  the  limb.  For  purposes  of  orientation 
an  assistant  was  kept  in  constant  readiness  to  rotate  the  femur 
while  the  operation  was  going  on.  The  bone  was  removed  in 
such  a  way  that  the  flat  pelvic  surface  w^as  tilted  up  mesially 
somewhat,  in  order  to  produce  a  locking  of  the  parts  and  to 
prevent  any  possible  dislocation  from  w^eight-bearing.  The  leg 
was  finall}^  put  up  in  a  spica  extending  from  the  axilla  to  the  toes, 
in  strong  abduction  and  10  degrees  of  flexion.  The  convalescence 
was  uneventful,  and  at  the  end  of  4  weeks  the  patient  was  walking 
with  the  aid  of  crutches.  A  short  spica  was  substituted  for  the 
long  one  at  the  end  of  5  weeks.  At  the  end  of  9  weeks  the 
patient  walked  without  the  aid  of  crutches  or  cane.  He  went 
back  to  work  as  a  patrolman  in  4  months.  The  patient  stated, 
2  years  and  3  months  after  the  operation,  that  he  had  not  suf- 
fered any  pain  w^hatever  since  he  left  the  hospital,  although  he 
was  at  work  continuously.  The  leg  remained  extremely  well 
in  the  corrected  position,  and  only  I4  in.  of  extra  leather 
was  worn  on  the  heel.  His  occupation  since  the  operation 
vouches  for  his  locomotive  abilities.  He  has  continued  as  a 
patrolman,  working  9  hours  a  day,  and  has  not  lost  any  time  on 
account  of  his  hip  since  he  went  back  to  work  in  September, 
1907.     (Note  of  March,  1910.) 

Case  II. — A.  N.,  consulted  the  author  on  September  14, 
1906.  Before  a  question  could  be  asked,  the  patient  volunteered 
the  diagnosis.  He  said  that  his  right  hip  had  been  fractured 
15  years  before.  The  following  history  was  obtained:  Age, 
30;  always  well.  No  trouble  with  joints  before  injury.  Was 
struck  on  right  hip  with  a  stone  the  size  of  a  goose  egg,  thrown 


REMODELLING    OR    ANKYLOSING    HIP-JOINT 


261 


by  his  brother,  15  years  before.  Careful  questioning  brought 
out  the  fact  that  he  walked  home  after  the  injury  and  did  not 
have  any  trouble  with  the  hip  for  over  a  year.  The  first  symp- 
tom was  stiffness,  slowly  increasing  until  pain  appeared  about 
a  year  and  a  half  ago.  Since  then,  notwithstanding  much  treat- 
ment by  many  physicians,  the  symptoms  have  increased  in 
severity  until  2  months  ago,  when  he  was  compelled  to  dis- 


FiG.  193. 


-Case  of  advauced  osteoai'thritis  with  flattening  of  the  femoral  head  and 
osteophytes  at  AB. 


continue  work.     Sleep  has  been  much  interfered  with  on  account 
of  pain. 

Physical  examination:  Pale  and  careworn.  Walks  with  a 
marked  right  limp.  No  other  joints  involved.  Actual  shorten- 
ing of  right  leg,  I3  in.;  practical  shortening,  1J2  in.  Rota- 
tion and  abduction  of  thigh  much  limited  by  obstruction. 
Flexion  to  100  degrees.  Hyperextension  much  limited.  Some 
spasm  of  muscle.     Atrophy  of  limb  was  marked.     The  buttock 


262  BONE-GRAFT    SURGERY 

was  flaccid  and  flattened.  A  rontgenogram  showed  the  head 
niucli  worn  away  and  flattened,  with  many  osteophytes  about 
the  rim  of  the  acetal)uhim. 

The  patient  was  put  to  ])e(l  with  traction  of  5  11).,  and 
the  hip  was  immobilized.  The  pain  promptly  disappeared, 
and  at  the  end  of  2  weeks  a  short  spica  was  applied  and  the 
patient  was  allowed  to  go  about  with  the  aid  of  crutches.  This 
was  very  annoying  to  him,  and  he  refused  to  wear  the  spica. 
A  brace  was  advised,  but  was  refused.  Patient  was  not  seen 
again  for  over  a  year.  When  he  reported,  he  had  been  taking 
some  injection  treatment  in  hip  and  was  much  worse  in  respect 
to  both  pain  and  disability.  He  was  admitted  to  the  New  York 
Post-Graduate  Hospital  November  25,  1907,  and  was  imme- 
diately operated  upon. 

This  patient  has  been  back  at  work  since  10  weeks  after  the 
operation,  and  he  has  been  entirely  relieved  of  pain. 

Case  III. — J.  K.,  referred  to  the  author  by  Dr.  A.  W.  Hollis, 
of  New  York.  He  was  previously  an  active  business  man,  63 
years  of  age.  Past  history  negative.  Twelve  years  ago  a 
sidewalk  over  which  patient  was  walking  broke,  letting  his  right 
leg  through.  The  right  hip  received  a  ''severe  jar."  Soon  after 
this  he  began  to  have  pain  in  the  knee  and  thigh,  especially 
while  walking.  Ten  years  ago  he  began  also  to  have  pain  in 
the  region  of  the  right  sciatic  nerve.  This  has  gradually  in- 
creased in  severity.  Three  years  ago  a  severe  pain  began  just 
posterior  to  the  hip-joint.  This  continued  to  increase  until,  for 
the  past  3  months,  the  patient  was  practically  confined  to 
his  chair  or  bed.  He  lost  interest  in  things  and  refused  to  go 
about,  and  retired  from  business. 

Physical  examination:  Patient  very  large:  height,  5  ft. 
11  in.;  weight,  220  lb.  Right  thigh  much  atrophied.  Patient 
walked  with  difficulty,  hopping  along  as  if  it  were  very  painful. 
Plexion  limited  to  about  two-thirds  its  normal  arc.  Abduction 
and  rotation  nearly  absent.  Limb  adducted:  actual  shorten- 
ing, :^8  in.;  practical    shortening,    I32    in.     Joint  sensitive  to 


REMODELLING    OR    ANKYLOSING    HIP-JOINT  263 

the  extremes  of  motion.     Patient  locates  most  severe  pain  just 
posterior  and  internal  to  the  hip-joint. 

He  was  admitted  to  St.  Luke's  Hospital,  private  pavilion,  by 
the  kindness  of  Dr.  Lyle.  The  operation  was  done  February 
20,  1908.  The  head  had  slipped  up  on  the  rim  of  the  acetabulum 
and  was  apparently  progressing  toward  a  complete  dislocation. 


Fig.    194. — Good  union  secured  in  a  case  of  advanced  osteoarthritis  of  the  hip 
by  author's  arthrodesis.      .4.  indicates  small  bone  grafts. 

There  were  many  osteophytes  and  much  disorganization  of  the 
joint. 

The  convalescence  was  uneventful.  This  wound  also  healed 
by  primary  union.  The  patient  was  walking  with  the  aid  of 
crutches  at  the  end  of  4  weeks,  and  could  place  his  whole 
weight  upon   the  operated  leg  without   pain.     The  spica  was 


264  BONE-GRAFT    SUK(iEl{Y 

cluinged  to  ii  slu)rt  one  at  the  eiiel  of  5  weeks.  This  was  re- 
moved at  the  end  of  11  weeks. 

This  patient  was  seen  Jun(^  1,  1908,  when  he  stated  that 
he  had  not  experienced  a  twinge  of  pain  in  his  hip  since  the 
operation.  His  family  stated  that  he  had  undergone  a  great 
change  mentally  since  relieved  of  his  constant  pain,  and  that 
he  was  much  more  cheerful  than  formerly.  In  a  letter  dated 
January  12,  1909,  the  patient  states :  "I  am  very  much  pleased 
to  be  able  to  report  that  the  operation  has  been  a  wonderful 
success.  All  pain  has  left  me,  and  you  may  remember  that  I 
was  very  anxious  about  my  right  knee-joint,  which  had  pained 
me  for  so  many  years  and  wdiich  I  feared  might  have  become 
chronic,  but  now  this  knee  is  as  strong  as  the  other  and  is 
entirely  free  from  pain.  I  can  walk  all  day,  if  necessary.  The 
resulting  freedom  from  pain  allows  me  to  attend  to  my  business 
and  I  feel  at  least  20  years  younger." 

Case  /F.— Miss  B.,  IS  years  of  age,  was  admitted  to  the 
New  York  Post-Graduate  Hospital  August,  1907,  and  a  diagnosis 
of  ankylosis  with  flexion  adduction  deformity  following  tuber- 
culosis of  hip  was  made,  and  a  Gant's  osteotomy,  with  correction 
of  the  deformity,  was  done.  The  immediate  convalescence  was 
uneventful,  but  when  the  patient  began  to  walk,  w^eight-bearing 
produced  pain  and  a  short  spica  with  crutches  was  instituted 
again,  but  to  no  avail.  A  rontgenogram  taken  1  year  after 
the  operation  showed  the  bones  well  united  at  the  point  of 
operation,  but  there  was  sHght  motion  at  the  hip-joint,  indicating 
that  the  ankylosis  was  fibrous  and  not  bony,  as  was  supposed — 
which,  by  the  way,  is  very  likely  to  be  the  case  in  tubercular 
infection,  and  accounts  for  the  frequent  relapse  of  the  deformity 
after  a  trochanteric  osteotomy.  In  this  case,  then,  we  had  an 
analogous  problem  to  that  of  a  knee-joint  in  a  similar  condition 
with  its  contingent  joint  strain,  the  universal  treatment  for  which 
is  an  excision  for  ankylosis.  After  palliative  treatment  for  1 
year  and  10  months,  without  relief,  a  partial  arthrectomy 
was  done  June  1,  1908.  The  hip  was  found  to  be  much  disinte- 
grated, but  the  ankylosis  was  fibrous.     The  convalescence,  in 


REMODELLING    OR   ANKYLOSING    HIP-JOINT  265 

a  neurotic  girl,  has  been  uneventful,  and  a  firm  bony  ankylosis 
has  been  secured. 

GRAFTING  OF  THE  ASTRAGALUS  TO  SECURE  AN  ABSENT  HEAD  AND 
NECK  OF  THE    FEMUR 

In  cases  of  loss  of  bone  substance  of  the  upper  end  of  the 
femur,  as  in  instances  of  destruction  of  the  head  and  neck  fol- 
lowing septic  arthritis,  or  of  deformity  of  the  head  following 
injury,  it  has  been  found  that  the  astragalus  furnishes  an  ex- 
cellent substitute  for  such  deficiency  or  deformity.  This 
operation  was  first  suggested  by  Roberts,  who  reported  five 
cases  that  underwent  such  treatment. 

In  one  instance  where  the  author  grafted  the  astragalus  to 
the  upper  end  of  the  femur  of  a  child  4H  years  old,  the  head  and 
neck  of  the  femur  had  been  destroyed  by  septic  arthritis,  8 
months  before  the  operation.  The  astragalus  used  in  this  in- 
stance was  removed  from  the  foot  of  a  young  woman  18  years 
of  age,  of  Polish  nationality,  and  had  been  kept  for  24 
hours  in  cold  storage  in  sterile  vaseline  at  4  to  5°  C.  Instead 
of  employing  a  metal  spike  or  screw  to  fix  the  adapted  portion  of 
the  astragalus  to  the  femur,  as  advised  by  Roberts,  a  live-bone 
dowel  spike  was  employed,  which  had  been  obtained  from  the 
tibia  of  a  colored  patient  26  years  old.  The  operation  was  done 
November  14,  1912.  When  last  seen,  8  months  after  the  opera- 
tion, the  child  was  walking  with  good  motion  of  the  joint  and 
with  no  shortening. 

Technique  of  Astragalus  Graft  for  Loss  of  Femoral  Head. — 
Author's  Modification  of  Roberts'  Technique. — The  hip-joint  is 
exposed  through  an  antero-lateral  incision  extending  from  just 
internal  to  and  below  the  anterior-superior  spine  of  the  ilium 
to  just  below  the  great  trochanter,  and  then  curved  backward 
toward  the  tuber  ischii  for  1  to  2  in.  The  skin  and  subcutaneous 
structures  are  dissected  up,  exposing  the  great  trochanter,  the 
tip  of  which  wdth  its  muscle  attachments  is  cut  through  with  the 
motor  saw  or  a  sharp  osteotome  and  mallet  and  lifted  up, 
exposing  the  joint  capsule.     The  latter  is  split  longitudinally, 


266 


BONE-GRAFT    SURGERY 


and  the  iiil(n'i()r  of  the  joint  cxaniinccl  to  dotoriiiiuc  the  condi- 
tion of  the  acetahnhir  cavity  and  of  the  roniaininfj;  i)orti()n  of  tlie 
neck  of  tlic  fcMnur.  The  i-cnmant  of  the  femoral  neck  is  ti'iinnied 
up  with  a  sharp  osteotome,  preparatory  to  fitting  the  adapted 
l)()rtion   of   the   astragalus   which   has   been    obtained   for   the 


Fig.  !'.(.").  (  hilil  (if  4^2  >ears  whose  head  and  neck  of  ff^mur  had  been  previously 
destroyed  by  a  suppurative  arthritis  of  the  hip.  This  portion  of  the  femur  had  been 
restored  6  months  before  by  the  implantation  of  the  head  and  neck  of  an  astragalus 
from  a  young  woman  and  kept  24  hours  in  cold  storag?  at  4  to  5°  C.  The  astragalar  graft 
was  held  in  place  by  a  peg  graft  made  from  a  strip  of  cortical  bone  removed  from  the 
tibia  of  a  young  man  on  the  same  afternoon.  This  rontgenogram  and  photograph 
were  taken  6  months  after  the  insertion  of  the  graft.      The  functional  result  is  excellent. 


graft  and  shaped  to  fill  the  space  resulting  from  the  absent 
femoral  head. 

The  astragalus  is  secured  in  position,  having  been  fitted 
accurately  so  that  its  head  rests  in  the  acetabulum  tightly,  its 
body  end  cut  with  the  motor  saw  to  contact  well  with  the 


REMODELLING    OR    ANKYLOSING    HIP-JOINT  267 

freshened  stump  of  the  neck  of  the  femur  and  at  a  proper  angle 
in  its  relation  to  the  shaft. 

The  large  motor  drill  is  now  driven  from  without  inward 
through  the  great  trochanter — remnant  of  the  femoral  neck — 
and  well  into  the  new  astragalus-graft  head,  and  the  drill,  being 
disengaged  from  the  motor,  is  left  in  position  while  the  live-bone 
dowel  is  being  prepared  from  a  segment  of  cortical  bone  removed 
from  the  crest  of  the  tibia  along  its  middle  and  lower  third. 
This  segment  of  the  tibia  is  passed  through  the  author's  motor 
lathe,  which  turns  out  a  dowel  to  fit  exactly  the  hole  drilled 
through  the  trochanter  into  the  grafted  astragalus.  When  the 
dowel  is  prepared,  the  drill  is  withdrawn  from  its  position  in  the 
trochanter  and  astragalus  graft  and  the  dowel  pin  is  driven  into 
position,  thus  securely  fixing  the  astragalus  graft  to  the  upper 
end  of  the  femur. 

The  author  believes  that  the  substitution  of  the  live-bone 
spike  in  place  of  the  metal  screw  is  very  essential  to  the  uniform 
success  of  this  procedure,  A  large  portion  of  the  astragalus 
graft  being  in  the  acetabular  cavity,  it  is  at  best  in  a  poor  en- 
vironment for  the  establishment  of  a  nourishing  blood  supply 
which  must  largely  come  through  its  contacted  end.  The  metal 
screw  not  only  diminishes  the  diameter  of  this  contacting  sur- 
face, but,  as  is  well  known,  produces  bone  absorption  and  de- 
struction, while  in  the  case  of  the  bone  graft  not  only  is 
efficacious  mechanical  fixation  furnished,  but  also  a  stimulative 
influence  to  the  callus  formation  of  the  contacting  bone  sur- 
faces supplied,  as  well  as  an  osteogenetic  force  provided,  at  the 
same  time  that  it  serves  as  an  osteoconductive  scaffold  well  into 
the  astragalus  graft.  This  feature  is  well  illustrated  also  in  the 
treatment  by  the  author's  method  of  fracture  of  the  neck  of  the 
femur  by  bone-graft  spike,  either  in  old  ununited  fractures  or 
in  fresh  unimpacted  fractures  with  malposition  of  the  fragments, 
requiring  an  operation  for  reduction  and  fixation. 

The  capsule,  if  distinguishable,  is  closed  with  small  kangaroo- 
tendon  suture;  the  tip  of  the  great  trochanter  is  replaced  and 
held  by  strong  kangaroo  sutures;  the  soft  parts  are  closed  in, 


268 


BONE-GRAFT    SURGERY 


and  the  skin  wound  is  closed  by  a  continuous  catgut  suture, 
without  drainage. 

The  leg  being  held  in  a  position  of  slight  abduction  and 
flexion  and  dressings  applied,  a  long  plaster-of-Paris  spica  is 
made,  reaching  from  the  toes  to  the  axilla,  which  remains  on  for 


Fig.   1!)()  Fig.  197 

Fig.  196. — Drawing  of  the  astragalus  and  the  portion  used  to  restore  the  head  of 
the  femur. 

Fig.  197. — Drawing  to  demonstrate  the  author's  modification  of  Roberts'  technique 
of  inserting  a  portion  of  an  astragahis  for  the  absence  of  the  head  and  neck  of  the  femur. 
The  dotted  Hnes  indicate  the  author's  tibial  bone-graft  peg,  which  not  only  holds  the 
astragalar  fragment  in  position,  but  also  serves  in  an  equally  important  role  of  furnishing 
both  an  bsteogenetic  and  osteoconductive  bridge  between  the  femur  and  the  astragalar 
graft. 

6  to  8  weeks,  after  which  time  a  short  spica  is  substituted  and 
worn  for  4  to  6  weeks  longer. 


THE  USE  OF  THE  BONE  GRAFT  TAKEN  FROM  EITHER  THE  TIBIA  OR 

FIBULA   TO    REPLACE   A   PORTION    OF   THE   UPPER   END    OF   THE 

FEMUR  REMOVED    ON   ACCOUNT    OF  BENIGN   NEW  GROWTHS 


The  Application  of  the  Autogenous  Bone  Graft  in  the  Opera- 
tive Treatment  of  Osteitis  Fibrosa  Cystica  of  the  Upper  End  of 
the  Femur. — In  cases  of  osteitis  fibrosa  cystica  with  a  gradual  ex- 
tension of  bone  involvement,  with  or  without  pain,  accompanied 


REMODELLING    OR    ANKYLOSING    HIP-JOINT 


269 


by  weakening  of  the  bony  structure  with  varying  degrees  of 
deformity  and  at  times  fracture,  either  the  segment  of  bone 
affected  should  be  removed  and  a  graft  of  bone — preferably 
removed  from  the  tibia — substituted  or,  if  there  is  but,  a  small 
portion  of  the  diameter  of  the  bone  involved,  that  portion  can 
be  chiselled  and  curetted  away  and  a  graft  of  bone  implanted 


Fig.   198. — Large  cyst  of  upper  end  of  femur  of  syphilitic  origin,  with  fracture  at  A. 
The  cyst  was  removed  and  a  strong  tibial  graft  inlaid.      (See  Fig.  199.) 

to  reinforce  the  weakened  area.  Numerous  cases  of  this 
character  have  been  reported  where,  if  substitution  had  not  been 
made  by  some  means,  as  by  grafting  bone,  great  bowing, 
shortening  and  crippling  deformity  would  have  resulted,  or  even 
amputation  would  have  been  deemed  advisable. 

In  cases  where  a  thorough  cleaning  out  of  this  cystic  fibrous 


270 


BONE-GRAFT    SURGERY 


portion  has  been  effected,  fracture  of  the  weakened  wall  has 
taken  place,  either  at  the  time  of  operation  or  at  some  subsequent 
period.  An  autogenous  graft  of  bone,  properly  adapted  and 
accurately  contacted  tiiroughout  the  weakened  area,  fulfils  all 


^  ^ 


>* 


Fig.  199. — Same  case  as  Fig.  198.  The  cyst  has  been  removed,  femur  somewhat 
straightened  and  the  graft  AB  inserted.  About  3  months  after  the  operation  the 
patient  fell  and  completely  fractured  the  graft  and  the  femur.  The  limb  was  put  in  a 
spica  and  the  graft  immediately  united. 

requirements  in  strengthening  and  preventing  further  distortion 
or  loss  of  function  by  excessive  shortening. 

Murphy  ("Surgical  Clinics,"  vol.  ii.  No.  5)  reports  three  in- 
stances where  such  a  procedure  was  adopted  by  him  in  osteitis 
fibrosa  cystica  of  the  upper  end  of  the  femur,  tibia,  and  humerus. 


EEMODELLING    OR    ANKYLOSING    HIP-JOINT 


271 


The  first  case  was  that  of  a  male,  27  years  of  age,  who  apphed 
for  treatment  on  account  of  deformity  of  the  right  thigh.  The 
history  states  that  when  the  patient  was  9  years  old  (1895)  he 
fell,  while  running,  and  landed  on  both  knees,  striking  harder 
on  the  right  than  on  the  left.     He  could  not  get  up  on  account 


Fig.  200. 


-AB  is  bone  graft  inserted  into  an  old  osteomyelitic  cavity  for  the  purpose  of 
supplying  bone  growth  to  fill  the  cavity. 


of  severe  pain  extending  from  the  right  hip  to  the  knee.  He 
was  confined  to  bed  for  2  weeks  after  the  injury  and  had  pain  in 
the  right  thigh  for  the  next  2  months.  No  chills  or  fever.  When 
14  years  old  (1900)  he  tried  to  jump,  slipped  and  fell,  one  leg 
extending  forward  the  other  backward.  He  immediately  had 
severe  pain  in  the  right  thigh  just  below  the  hip,  was  unable  to 
rise,  and  was  carried  home.  Acute  pain  continued  for  the  next 
2  weeks,    shooting  in  character,  extending  down  the  right  thigh 


272 


BONE-GRAFT    SURGERY 


to  the  kiieo.  The  slightest  movement  of  the  leg  increased  the 
severity  of  the  pain.  It  gradually  subsided,  but  continued  as  a 
dull  pain  for  the  following  3  months.  At  the  end  of  3  months 
he  was  al)lo  to  walk,  and  after  6  months  he  was  free  from  pain. 
When  the  pain  ceased,  he  noticed  a  change  in  his  gait.  The  right 
leg  seemed  to  be  shorter  than  the  left,  and  slight  bowing  ap- 
peared in  the  upper  third  of  the  thigh.     Riintgenograms  were 


jFiG.  201. — Skiagram  made  two  months  before  operation.  By  comparing  these 
five  skiagrams  the  progress  of  the  disease  is  well  shown.  The  articular  surface  of  the 
head  of  the  humerus  does  not  appear  to  be  involved  at  any  time.  The  epiphyseal  line 
is  well  shown,  and  the  change  in  its  direction  occurring  with  the  growth  of  the  tumor 
is  marked.      (Clinics  of  John  B.  Murphy,  M.  D.) 

taken,  and  it  was  judged  that  a  green-stick  fracture  had  oc- 
curred with  a  possible  focalization  of  a  low  type  of  infection, 
which  is  considered  a  cause  of  osteitis  fibrosa  cystica.  Bowing 
gradually  increased,  and  after  walking  a  little  distance  pain  was 
experienced;  shortening  was  compensated  for  by  the  addition 
of  a  high  shoe.  There  was  a  history  of  a  Neisserian  infection, 
also  he  has  had  measles,   scarlet   fever,  whooping-cough,   and 


REMODELLING    OR    ANKYLOSING    HIP-JOINT 


273 


pneumonia.  No  history  of  lues.  Family  history  negative. 
The  rontgenogram  illustrates  a  typical  case  of  osteitis  fibrosa 
cystica  (Figs.  201  to  205). 

The  technique  of  operation  was  as  follows:     An  incision 
was  made  on  the  outer  aspect  of  the  thigh,  between  the  flexor 


Fig.  202.  Fig.  203. 

Fig.  202. — Skiagram  made  immediately  after  the  operation.  The  lower  end  of 
the  transplant  is  impacted  in  the  medullary  canal,  and  the  remaining  portion  of  the  shaft 
of  the  humerus  is  fixed  with  a  small  wire  nail.  The  upper  end  of  the  transplant  is  in 
the  glenoid  cavitj-,  the  capsule  of  the  joint  having  been  sutured  around  it.  (Clinics  of 
John  B.  Alurphy,  M.  D.) 

Fig.  20.3. — Skiagram  made  about  5  weeks  after  operation.  The  arm  is  a  little 
straighter  than  in  the  preceding  skiagram.  Bone  regeneration  is  progressing  well, 
and  the  periosteum  is  still  plainly  to  be  seen.      (Clinics  of  John  B.  Murphy,  M.  D.) 

and  extensor  groups  of  muscles  and  directly  over  the  lesion, 
and  by  resecting  the  soft  parts  the  tumor  was  exposed.  The 
overlying  periosteum  was  incised  and  easily  lifted  free  by  a  perios- 
teal elevator,  as  it  was  deemed  advisable  to  save  it.  The 
canopy  or  roof  of  the  tumor  was  broken  down  with  a  chisel  so 

18 


274 


BONE-GHAFT    SURGERY 


as  to  expose  the  cyst  pockets  underlying,  which  were  cleaned 
out  thoroughly  preparatory  to  inserting  the  transplant,  which 
was  applied  on  the  slant  through  the  affected  area.  The  lining 
granulation  tissue  was  removed  with  a  curette.  The  walls  be- 
tween the  pockets  were  broken  down  sufficiently  to  admit  the 
graft.     Care  was  taken  not  to  fracture  the  femur  during  this 


J'"" 


Fig.  2U4.  Fig.   205. 

Fig.  204. — Skiagram  taken  16  weeks  after  operation.  Bone  regeneration  is  pro- 
gressing rapidly.      (Clinics  of  John  B.  Murphy,  M.  D.) 

Fig.  205. — Skiagram  taken  about  YVi  months  after  operation.  The  upper  end  of 
the  humerus  has  been  regenerated  to  a  considerable  extent,  including  the  tuberosity 
and  the  articular  surface.  The  white  line  a  little  to  the  right  of  the  central  axis  of  new 
part  of  the  shaft  represents  the  periosteum  which  was  left  on  the  transplant.  The  new 
bone  is  slightly  thicker  than  the  old  ]jone.      (Clinics  of  John  B.  Murphy,  M.  D.) 

process,  as  the  result  of  this  cleansing  out  of  the  cyst  pockets 
left  but  a  thin  cortex  to  the  shaft.  From  the  crest  of  the  tibia 
of  the  other  leg,  a  graft  with  its  periosteal  covering  attached  was 
removed  in  the  usual  way,  the  transplant  measuring  7  in.  in 
length  by  }4  X  }i  X  H-  The  graft  was  placed  in  its  bed 
and  the  wound  closed  by  approximating  the  cut  edges  of  the 


REMODELLING    OR    ANKYLOSING    HIP-JOINT  275 

aponeurosis  with  plain  catgut,  and  the  skin  edges  with  horse- 
hair. By  placing  the  aponeurosis  sutures  well  back  from  the 
edges,  the  muscle  was  caused  to  roll  into  the  bone  cavity  and 
fill  it  when  the  suture  was  drawn  taut.  As  both  ends  of  the 
graft  were  securely  bound  by  a  shelf  of  bone,  no  nailing  was 
necessary.  The  periosteal  surface  of  the  graft  was  turned  out- 
ward. The  usual  dressing  was  applied  and  a  Buck's  extension 
with  a  25-lb.  weight  attached.  The  patient  remained  in  bed 
for  7  weeks  with  extension.  The  wound  healed  per  primmn. 
The  stitches  were  removed  an  the  seventeenth  day,  when  the 
first  dressing  was  made.  After  7  weeks  the  patient  was 
allowed  up  and  about  on  crutches.  He  was  without  pain  or 
discomfort  in  the  leg. 

The  author  believes  that  in  all  instances,  when  possible,  the 
inlay  method  of  fixing  the  graft  into  the  fragments  on  either  side 
of  the  hiatus  left  by  the  removal  of  the  tumor  should  be 
employed. 


CHAPTER  VI 

THE  INLAY  BONE  GRAFT  FOR  FIXATION  OF  TUBERCULOUS 
KNEE-JOINTS ;  INFANTILE  PARALYSIS ;  OSTEOARTHROP- 
ATHY   (CHARCOT'S   DISEASE);   THE  WEDGE  GRAFT 
FOR  HABITUAL  DISLOCATION  OF  THE  PATELLA 

The  knee-joint,  unlike  the  hip-joint,  is  situated  superficially 
and  is  not  deeply  covered  by  musculature.  Early  recognition 
of  disease  is  possible,  and  because  of  the  size  and  character  of 
the  joint  architecture,  together  with  the  long  leverage  control, 
made  possible  by  its  position  at  the  ends  of  long  bones,  the  con- 
trol of  joint  motion  is  easily  maintained. 

Tuberculous  Osteitis  in  Childhood. — Tuberculous  osteitis 
of  the  knee  is  not  so  frequently  met  with  in  childhood  as  is 
tuberculous  infection  of  the  spine  or  hip.  Compared  with  other 
lesions  of  the  knee-joint,  it  is  the  most  common.  Primary 
tuberculous  involvement  of  the  joint  synovia  in  children  is  rare. 
The  joint  invasion  is  from  a  primary  bone  focus  in  either  the 
upper  end  of  the  tibia  or  the  lower  end  of  the  femur,  which 
gradually  extends  and  involves  the  joint  structures.  Occasion- 
ally the  patella  is  found  to  be  the  seat  of  the  infection. 

The  characteristic  symptoms  of  tuberculous  osteitis  manifest 
themselves  at  a  very  early  stage  in  the  disease,  and  readily 
suggest  themselves  to  the  experienced  clinician.  Occasionally 
other  causes  of  the  local  symptoms  are  present  which  must  be 
borne  in  mind — as  acute  infections  and  gonorrhoeal  arthritis, 
acute  articular  rheumatism,  haemophilia,  syphilis,  sarcoma, 
Charcot's  disease,  arthritis  deformans,  hysterical  joint — from 
which  the  tuberculous  infection  should  be  differentiated,  by  the 
special  means  of  investigation  at  hand,  to  eliminate  error.  The 
rontgenogram  should  always  be  resorted  to,  and  both  the  well 
knee  and  the  involved  knee  should  be  taken  for  comparison  in 
the  two  planes,  lateral  and  antero-posterior. 

276 


THE    INLAY   BONE    GRAFT  277 

As  in  other  joints  infected  with  tuberculosis  in  childhood, 
the  essential  treatment  is  conservative  when  a  distinct  focus 
cannot  be  localized  and  removed,  and  a  well-ordered  regime  of 
life,  plenty  of  fresh  air,  sunlight,  and  a  full  diet,  varied  and  of 
an  easily  assimilated  character,  are  important  factors  in  the 
treatment. 

Local  treatment  consists  of  uninterrupted  immobilization  of 
the  joint  as  the  prime  factor  in  arresting  the  activity  of  the 
disease  and  the  prevention  or  correction  of  deformity.  The 
drainage  of  a  tuberculous  abscess  should  be  avoided,  as  it  is 
impossible  to  guard  against  mixed  infection  after  drainage 
is  established.  Infection  will  occur,  although  dressings  may  be 
made  ever  so  carefully,  especially  as  the  sinus  is  liable  to  persist 
for  a  long  period  of  time,  and  repeated  dressings  are  necessary. 
This  rule  does  not  apply  to  the  aseptic  incising  of  an  uninfected 
cold  abscess  and  the  immediate  closure  of  the  abscess  incision 
by  carefully  placed  subcutaneous  and  skin  sutures  after  the  con- 
tents have  been  evacuated.  Excision  of  the  joint  should  be 
abstained  from  in  all  cases  where  the  patient  is  under  16  to  18 
years  of  age,  on  account  of  the  damage  to  the  epiphyseal  carti- 
lages and  the  extreme  shortening  of  the  limb  resulting  therefrom. 

Tuberculous  Osteitis  in  the  Adult. — In  late  adolescent  and 
adult  life  where  the  prognosis  is  much  more  unfavorable  and  time 
is  such  an  important  factor  to  the  individual  with  a  tuberculous 
knee,  more  radical  treatment  has  been  resorted  to  in  the  effort 
to  arrest  the  disease,  relieve  pain,  prevent  relapse,  and  provide 
a  useful  limb  at  an  earlier  period  than  could  be  expected  by 
conservative  treatment. 

Rogers,  in  a  statistical  paper  in  the  American  Journal  of 
Orthopaedic  Surgery,  April,  1915,  states  that  of  100  consecu- 
tive cases  of  adult  tuberculous  osteitis  of  the  knee  treated  by 
conservative  methods  at  the  Massachusetts  General  Hospital 
from  1900  to  1907,  the  general  trend  was  progressively  bad  and 
always  came  to  excision  or  an  amputation  as  an  end  result 
within  4  years'  time.  There  was  no  record  of  any  cured  case 
by  the  conservative  method.     He  also  states,  from  the  study 


278  BONE-GRAFT   SURGERY 

of  47  operated  cases,  that  "the  effect  of  an  excision,  no  matter 
how  stormy  a  convalescence  there  was  nor  the  length  of  time 
required  to  obtain  ankylosis,  caused  the  active  tuberculosis  to 
become  quiescent." 

Operative  procedure  has  proved  achantageous  in  properly 
selected  adult  cases,  while  in  childhood  it  has  been  very  bad 
practice.  In  the  adult  there  exists  a  full  development  of  bone 
and  joint  structure,  and  therefore  excessive  shortening  from 
interference  with  the  epiphyses  is  eliminated.  In  long-standing 
cases  angular  deformity,  resisting  correction  by  the  usual  con- 
servative measures,  is  readily  remedied,  and  firm  bony  union 
between  femur  and  tibia  is  the  result.  Formerly,  excision  of  the 
knee  was  undertaken  with  the  primary  object  of  the  removal 
of  all  the  tuberculous  tissues,  and  the  production  of  an  ankylosis 
was  considered  of  secondary  importance.  This  led  to  excessive 
removal  of  bone,  with  shortening;  to  the  lessening  of  the  diame- 
ters of  the  opposed  ends  of  the  femur  and  tibia  on  account  of 
the  bone  incisions  being  made  above  the  expansions  of  the 
femoral  condyles  and  below  the  tibial  head;  to  prevention  of 
the  approximation  of  the  incised  bone  end  surfaces  resulting 
often  in  non-union ;  and  to  the  constant  liability  of  not  removing 
all  tuberculous  tissues. 

In  a  large  percentage  of  cases  subjected  to  this  measure 
the  results  are  not  ultimately  satisfactory,  and  not  a  few  come 
later  to  an  amputation  of  the  limb,  either  as  a  life-saving  measure 
or  in  order  to  allow  the  application  of  a  serviceable  artificial  limb 
on  account  of  the  failure  of  bony  union  or  the  occurrence  of 
excessive  deformity. 

It  has  been  found  by  experienced  operators  that  the  es- 
sential factor  in  the  arrest  of  a  tuberculous  process  of  the  joint 
is  the  production  of  a  bony  ankylosis.  This  point  has  been 
strongly  emphasized  by  Ely  in  his  writings,  and  has  been  fol- 
lowed by  such  satisfactory  results  that,  in  the  author's  opinion, 
it  cannot  be  too  emphatically  advised.  As  the  chief  considera- 
tion rests  upon  the  production  of  bony  ankylosis  in  these  adult 
tuberculous  knees,   it   is   the  author's  purpose  to   outline  his 


THE    INLAY   BONE    GRAFT  279 

methods  of  technique  which  experience  has  proved  to  be  the 
most  certain  and  reliable. 

First,  to  emphasize  more  forcibly  the  accuracy,  ease,  and 
certainty  of  these  methods,  some  statistics  of  methods  and  re- 
sults as  applied  by  other  authors  will  be  reviewed  for  contrast, 
as  for  example  28  consecutive  excisions  of  the  knee  for  tubercu- 
losis, done  in  the  period  from  1907  to  1913  in  the  orthopaedic 
service  of  the  Massachusetts  General  Hospital  by  different 
orthopaedic  surgeons,  reported  by  Osgood,  and  this  report  is 
herewith  abstracted  by  the  author. 

The  cases,  following  at  least  a  month's  fixation  in  plaster 
so  as  to  render  the  disease  somewhat  quiescent,  receive  a  2-  to 
4-day  preparation  of  the  knee.  On  the  table  benzine-iodine 
skin  preparation  is  given,  and  an  Esmarch  or  tourniquet  is 
applied.  The  usual  U-shaped  incision  is  made  from  above  one 
femoral  condyle  to  the  other,  crossing  the  patellar  tendon  about 
an  inch  above  its  insertion.  The  proximal  cut  end  of  the  patellar 
tendon  is  seized  and  turned  back,  with  all  the  structures  over- 
lying the  joint  included,  dissected  up,  and  the  knee  gently  flexed 
as  the  dissection  takes  place.  Much  of  the  exposed  tuberculous 
tissue  is  removed,  and  the  articular  ends  of  femur  and  tibia  de- 
veloped. Only  sufficient  bone  is  sawed  off  the  articulating  ends 
of  the  femur  and  tibia  to  reach  beyond  the  disease,  and  the 
patella  is  either  removed  or  its  under  surface  saw^ed  off.  Only 
evident  masses  of  diseased  soft  parts  are  removed.  Bone  and 
soft-tissue  surfaces  are  swabbed  with  tincture  of  iodine.  The 
tourniquet  is  removed  and  bleeding  controlled. 

For  the  past  4  years  the  custom  in  the  orthopaedic  service, 
in  the  absence  of  a  sinus  or  a  mixed  infection,  has  been  to  fix  the 
bone  ends  by  malleable  iron  plates  or  aluminum  wire  clamps 
screwed  in  place  by  steel-wood  screws,  with  the  thread  cut  to  the 
head.  A  test  of  the  fixation  is  demonstrated  by  lifting  the  leg  by 
the  foot.  The  patellar  ligament  is  reunited,  as  well  as  the  deep 
structures  overlying  the  joint,  followed  by  the  skin-flap  suture, 
and  the  limb  is  placed  in  a  plaster  splint  which  is  changed  in  4 
weeks  when,  if  favorable,  the  patient  is  discharged  in  a  plaster 


280  BONE-GRAFT    SURGERY 

splint,  with  crutches.  The  iiiiincdiate  post-operative  freedom 
from  pain,  together  with  the  earher  firm  union,  by  these  methods 
of  fixation  was  noted. 

End  Results  Obtained  by  this  Plating  Fixation,  above  Described. 
— Comparison  is  made  in  the  reported  28  cases  between  the 
results  when  metal  plating  was  used  and  when  simple  excision 
was  performed.  Of  the  14  simple  excisions,  including  2  cases 
wired  by  silver  wire,  4  had  a  second  operation  for  re-excision, 
and  2  of  these  and  1  other  were  subsequently  amputated  to 
save  life.  Four  had  sinuses  before  the  operation,  and  9  after. 
Pain  persisted  several  months  after  operation  in  5  cases.  Even- 
tual union  occurred  in  6.  The  time  of  union  was  2  months 
or  less  in  2;  3  months  or  more  in  11;  and  there  is  no  record  of 
eventual  union  in  5.  In  both  cases  in  which  wire  was  used 
it  had  to  be  subsecjuently  removed. 

Comparing  the  cases  where  metal  clamps  or  plates  (8  clamps 
and  6  plates)  were  used:  None  required  a  re-excision.  One 
case  was  amputated  later,  because  of  secondary  infection.  Two 
had  sinuses  before  operation;  5  had  sinuses  after  operation.  All 
healed  except  1.  Pain  persisted  several  months  after  the 
operation  only  in  the  amputated  case,  and  to  a  slight  degree  in 
1  other  case  for  4  months  after  operation.  Eventual  union 
occurred  in  13.  Time  of  apparent  firm  union  was  1  month 
or  less  in  6  cases;  2  months  or  less  in  4;  and  3  months  or 
more  in  3.  In  5  cases  the  metal  clamps  or  plates  gave  subse- 
quent trouble  and  were  removed. 

From  the  foregoing  report,  it  is  obvious  that  the  actual 
fixing  together  of  the  denuded  bone  ends  has  a  decided  advan- 
tage, not  only  in  rehef  of  pain  but  in  hastening  bony  union, 
but  it  is  also  apparent  here,  as  has  been  the  universal  experience 
of  other  users  of  foreign  material  in  securing  bone  fixation,  that 
the  removal  of  the  metal  at  a  subsequent  operation  was  neces- 
sitated on  account  of  the  trouble  it  was  causing. 

From  the  author's  experience,  it  is  reasonable  to  beheve  that 
had  autogenous  bone  grafts  been  used  for  fixation  purposes, 
a  subsequent  operation  (for  the  removal  of  the  metal  clamp) 


THE    INLAY   BONE    GRAFT  281 

with  the  accompanying  disturbance  and  inconvenience  could 
have  been  avoided.  For  a  fuller  amplification  of  this  point, 
the  reader  is  referred  to  the  chapters  (IV  and  I)  on  the  treat- 
ment of  fractures  and  the  fundamental  principles  involved  in 
the  use  of  the  bone  graft. 

As  compared  with  the  foregoing  report  of  28  cases  done 
by  various  men  at  the  Massachusetts  General  Hospital  in 
the  5  years  mentioned,  the  author  outlines  his  technique  of 
application  of  the  inlay  bone  graft  in  his  fixation  operation  for 
tuberculous  knee-joint  disease  in  late  adolescence  and  in  the 
adult.  During  the  past  2  years  10  cases  have  been  done,  the 
3^oungest  patient  being  18  years  of  age,  and  bony  union  was 
obtained  in  every  instance  in  6  weeks'  time,  as  shown  clinically 
and  by  the  rontgenogram.  In  every  case  the  graft  has  taken, 
and  in  no  instance  has  it  come  out  or  had  to  be  removed.  These 
cases,  as  well  as  various  other  applications  of  the  bone  graft 
in  tuberculous  joints  where  they  span  through  tuberculous  areas, 
have  conclusively  proved  the  resistance  of  the  bone  graft  to  that 
infection  as  well  as  to  attenuated  pyogenic  infections  elsewhere 
described  (Chapters  I  and  IV).  In  view  of  these  facts  and  the 
excellent  mechanical  fixation  afforded  by  the  inlays,  as  well  as 
the  stimulation  to  osteogenesis  on  the  part  of  the  host  bone  and 
the  osteogenetic  force  which  the  bone  graft  exhibits,  its  striking 
advantage  over  metal  for  the  purpose  not  only  of  securing  bony 
union,  but  of  securing  it  early,  is  apparent.  No  pain  was  ex- 
perienced after  the  inlay-graft  method,  and  the  patients  were 
up  and  walking  in  their  plaster  splints  in  6  weeks'  time,  with  the 
aid  of  crutches.  Where  formerly  a  long  plaster-of-Paris  spica 
was  relied  upon  for  the  fixation  and  relief  from  pain,  following 
the  ordinary  excisions,  it  is  found  that  a  simple  plaster  splint 
extending  from  the  toes  to  the  groin  is  sufficient. 

The  Author's  Technique  as  Applied  to  the  Knee. — Following 
the  usual  preparation  of  the  patient,  including  the  application 
of  a  tourniquet,  access  to  the  knee-joint  is  through  a  U-shaped 
incision  reaching  from  one  femoral  condyle  to  the  other  and 
crossing  the  patellar  ligament  about  1  in,  above  its  insertion. 


282 


EONE-GRAFT    SURGERY 


The  patellar  ligament  is  divided,  and  the  deep  structures  over- 
lying the  joint  are  dissected  up  and  turned  back,  freely  exposing 
the  articular  surfaces.  The  crucial  ligaments,  if  present,  are 
divided,  as  well  as  the  lateral  ligaments  of  the  joint,  and  the 
upper  end  of  the  til)ia  is  drawn  forward  and  fixed. 

With  a  narrow-bladed  bow-saw,  the  upper  articular  surface 
of  the  head  of  the  tibia  is  removed,  cutting  transversely  and 


Fig.   206. — Illustrates  method  of  removing  posterior  infected  or  cartilaginous  surface  of 
1  patella  before  enucleation  and  forming  into  inlay  grafts.      (See  Fig.  207.) 


forming  a  flat  concave  surface  from  before  backward.  With  the 
same  saw,  the  articular  surfaces  of  the  condyles  of  the  femur  are 
removed,  forming  a  flat  ovoid  surface  from  before  backward, 
to  fit  the  concavity  of  the  upper  cut  end  of  the  tibia.  These 
surfaces  are  apposed. 

With  the  twin  motor  saw,  two  gutters  are  formed  across 
this  line  of  apposed  femur  and  tibia.     One  gutter,  about  ^2  in. 


THE    INLAY   BONE    GRAFT 


283 


wide  and  2  in.  long,  depending  upon  the  size  of  the  patella, 
is  made  from  the  external  condyle  into  the  outer  and  anterior 
portion  of  the  head  of  the  tibia,  and  another  gutter  of  the  same 
dimensions  is  formed  across  from  the  internal  condyle  to  the 
inner  anterior  surface  of  the  head.  The  segments  of  bone 
filling  these  gutters  are  cut  across  at  the  ends  of  the  gutters  with 


B  C 

Fig.  207. — A  shows  the  line  of  removal  of  the  articulating  surface  of  femur  and  tiljia 
by  the  narrow  bow-saw  in  producing  the  arthrodesis  of  the  knee-joint.  B,  the  splitting 
of  the  patella  into  segments  by  the  twin  motor  saw,  to  produce  two  bone  grafts  to  be 
placed  in  gutters  C  sawed  from  the  two  condyles  of  the  femur  into  the  head  of  the  tibia 
by  the  twin  motor  saw  adjusted  at  the  same  distance  apart  as  when  cutting  the  two  in- 
lay grafts  from  the  patella. 


the  small  motor  saw  and  are  removed  with  the  aid  of  a  thin, 
narrow,  sharp  osteotome. 

The  twin  motor  saw,  adjusted  to  the  same  width  as  when 
forming  the  gutters,  is  used  in  cutting  from  the  patella  two 
strips  which  are  used  to  span  between  the  femur  and  tibia  and 
fit  tightly  into  the  previously  prepared  gutters.  Holes  are 
drilled  on  either  side  of  the  gutters  with  the  small  motor  drill, 


284 


BONE-GRAFT    SURGERY 


in  both  the  femoral  condyles  and  head  of  the  tibia,  and  strong 
kangaroo-tendon  sutures  are  passed  and  tied  over  both  ends  of 
the  two  patellar  grafts,  holding  them  securely  in  position. 

It  is  to  be  noted  that  only  sufficient  bone  is  removed  from  the 
articulating  surfaces  of  the  tibial  tuberosities  and  femoral  con- 


FiG.  208. — Cured  tuberculous  knee.  Rontgenogram  taken  6  months  after  arthro- 
desis and  the  insertion  at  arrow  points  of  inlay  graft  formed  from  the  patella.  There 
was  firm  union  in  6  weeks. 

dyles  to  furnish  closely  apposed  raw-bone  surfaces;  and  only 
apparent  and  easily  accessible  tuberculous  infected  soft  tissues 
are  cut  away,  together  with  whatever  synovia  that  can  be  easily 
reached  with  curved  scissors.  No  undue  effort  is  made  to 
remove  all  tuberculous  bone,  so  that  very  little  additional  short- 


THE    INLAY    BONE    GRAFT 


285 


ening  results  from  the  operation.  If  the  patella  is  found  to  be 
tuberculous — which  is  rare — it  is  discarded  and  a  bone  graft  about 
3  in.  in  length  is  removed  from  the  antero-internal  surface  of 
the  tibia  to  supply  the  two  bone  inlay  grafts.     The  grafts  can 


Fig.  209. — A  cured  tulierculous  knee.  Tibial  inlay  grafts,  each  2  in.  long,  were 
placed  at  A  and  B  equally  into  condyles  of  femur  and  head  of  tibia  18  months  before. 
Firm  union  occurred  in  5  weeks.  The  grafts  have  become  altered  to  the  bone  structure 
in  which  they  are  imbedded  and  do  not  show  prominently  in  the  rontgenogram. 


easily  be  made  of  this  length,  as  they  are  not  limited  by  the 
size  of  the  patella.  The  other  dimensions  of  these  grafts 
should  comprise  a  width  of  }i  in.  and  the  entire  thickness  of  the 
cortex  to  the  marrow  cavity,  according  to  the  size  of  the  patient. 


2S()  BONE-GRAFT   SUIKJEHY 

111  applying  the  inlay  bone  graft  for  ununited  fracture  of  a 
long  bone,  the  inlay  graft  can  be  easily  fixed  in  position,  pref- 
erably by  kangaroo  tendon  or  by  bone  pegs  formed  of  additional 
bone  strips  removed  from  the  crest  of  the  tibia  at  the  time  the 
inlay  segment  is  removed.  This  additional  strip  of  inlay  bone 
is  split  lengthwise  into  suitable  pieces  to  form  the  bone  pegs, 
which  is  done  by  passing  them  through  the  small  cutter  of  the 
motor  lathe  to  fit  the  drill  holes  made  by  the  corresponding 


Fig.  210. — Rontgenogram  of  a  flail  knee  following  an  excision  of  the  joint.  The  lib- 
eral removal  of  bone  has  resulted  in  non-union  and  a  limb  perfectly  useless.  This  con- 
dition could  have  readily  been  avoided  by  simply  producing  an  arthrodesis  after  a  more 
conservative  removal  of  bone  and  the  implantation  of  inlay  grafts.  Sinuses  still  per- 
sist and  the  result  is  a  failure. 

motor  drill.  As  these  drill  holes  are  made  to  diverge  from  the 
graft  into  the  receiving  bone  and  are  placed  at  or  through  the 
edges  of  the  graft,  it  is  readily  seen  that  when  the  bone  graft 
pins  are  inserted  they  bind  the  graft  securely  in  position  and  no 
retaining  sutures  are  required.  If  space  permits,  four  pins  can 
be  inserted  at  either  end  of  each  graft,  into  the  femur  and  into 


THE    IXLAY   BONE    CxRAFT 


287 


the  tibia — two  on  each  side  at  each  end  into  the  respective  bones 
—but  one  on  each  side  at  each  end  is  usually  sufficient. 

The  soft  structures  are  replaced  over  the  operated  field  and 
sutured;  the  sound  patellar  ligament  is  reunited  with  chromic 
catgut  sutures,  and  the  skin  is  closed  by  a  continuous  catgut 
mattress  suture,  without  drainage. 

The  limb,  being  now  made  secure  by  the  inlays,  is  placed  in 


Fig.  211. — Arthrodesis  of  the  knee-joint  with  two  tibial  inlay  grafts  implanted  span- 
ning the  apposed  ends  of  femur  and  tibia.  These  grafts  are  imbedded  and  pinned  in 
with  autogenous  bone  dowel  pins,  or  held  in  place  with  kangaroo  tendon. 


a  plaster-of-Paris  splint  reaching  from  the  toes  to  the  groin. 
The  tourniquet  is  not  removed  until  the  plaster  dressing,  with 
firm  even  compression  about  the  knee,  has  been  applied  to  the 
limb  from  the  foot  to  the  tourniquet.  This  is  important,  and 
should  never  be  overlooked.  The  removal  of  the  tourniquet 
before  the  compressive  dressing  is  applied  allows  uncontrolled 
bone  ooze,  and  leads  to  a  tourniquet  paralytic  dilatation  of  the 


288 


B()ne-(;kaft  surgery 


arterioles;  also  the  rubbing  of  the  bone  surfaces  on  each  other 
(hiring  the  apphcation  of  the  dressing,  dislodges  the  adherent 
blood-clots  and  prevents  hsemostasis  {i.e.,  if  the  tourniquet  is  re- 
moved before  the  application  of  the  fixation  dressing). 

It  has  been  found  unnecessary  to  continue  the  plaster  splint 


Fig.  212. — To  illustrate  the  potency  of  ^\  nlt'f's  law.  Thi.s  is  a  lateral  view  of  an 
ankylosed  knee  which  is  the  result  of  a  stiffening  operation  for  tuberculous  osteitis. 
Delayed  union  and  insufficient  post-operative  support  resulted  in  a  flexion  deformity 
to  nearly  a  right  angle.  Weight-bearing  under  these  disadvantageous  conditions  caused 
the  hypertrophy  of  the  shafts  of  the  tibia  and  femur  at  and  near  the  angulation.  The 
cortex  at  A  and  B  is  two  to  three  times  its  normal  thickness. 


above  the  groin,  as  was  formerly  required  to  insure  against  dis- 
placement and  pain.  The  splint  is  left  on  for  4  weeks,  at  which 
time  it  is  changed  and  the  patient  is  allowed  up  on  crutches. 
The  second  plaster  splint  can  usually  be  discarded  in  from  4 
to  6  weeks. 

There  is  no  doubt  that  the  accurate  mortising  together  of 


THE    INLAY   BONE    GRAFT 


289 


the  femur  and  tibia  by  the  graft  hastens  firm  ankylosis  and 
renders  it  more  certain;  also  that  the  post-operative  relief 
from  pain  experienced  by  these  patients  following  the  inlay  fixa- 
tion offers  a  great  advantage  over  the  former  simple  excision  of 
the  knee.     As  compared  with  the  fixation  methods  referred  to 


Fig.  213. — An  angular  bony  ankylosis  of  the  knee-joint,  the  wedge  A  removed 
from  the  convex  side  of  the  deformity  and  A'  the  cutting  of  this  wedge  with  the  twin 
saw  to  form  one  large  bone-graft  inlay,  to  be  implanted  in  the  anterior  surfacejof  the 
knee  to  span  from  femur  to  tibia  when  the  leg  is  straightened. 


when  metal  plates  or  clamps  were  used,  there  can  be  no  question 
but  that  the  autogenous  bone  graft  applied  in  these  cases  for 
fixation  has  a  decided  advantage.  The  same  role  is  played  by 
the  bone  graft  in  this  instance  as  in  its  application  elsewhere  in 
bringing  about  firm  union  between  bones  or  fragments  of  bone. 


290 


BONE-GRAFT    SURGERY 


It  stimulates  osteogenesis;  whereas  the  metal,  when  used,  fur- 
nishes only  temporary  fixation  and  inhibits  osteogenesis  in  its 
immediate  vicinity,  exposes  the  parts  to  infection,  and  in  certain 
instances  contributes  to  the  necessity  of  a  subsequent  operation 
for  amputation  or  the  removal  of  the  offending  metal. 


Fig.   214.— Twin  saw-cuts  to  form  gutter  for  inlay  graft  after  wedge  has  been  removed  as 

shown  in  Fig.  213. 


Fig.   215. — Method  of  removing  strips  of  bone  between  twin  saw-cuts  to  form  gutter  for 

inlay  graft. 

THE  USE  OF  THE  BONE  GRAFT   FOR  STIFFENING   THE  KNEE-JOINT 
IN  INFANTILE  PARALYSIS 

Extensive  or  partial  paralysis  of  the  muscles  controlling  the 
knee-joint   often   causes   instability  to  such  a  degree  that   the 


THE    INLAY   BONE    GRAFT 


291 


patient  cannot  bear  weight  upon  the  affected  Hmb,  in  walking 
or  standing,  without  its  giving  way  beneath  him.  Such  patients 
should  be  informed  of  the  advantages  and  disadvantages  to  be 
expected  from  stiffening  the  knee-joint,  whether  by  the  employ- 
ment of  a  brace  with  a  mechanical  joint  at  the  knee  or  by  pro- 
ducing a  permanently  stiff  knee  by  a  bone  operation. 

In  some  instances  where  the  paralysis  is  not  too  extensive, 
the  transference  of  one  or  two  of  the  flexor  muscles  of  the  knee, 
taking  the  place  of  extensors,  is  of  advantage,  as  in  the  instances 
where  the  insertion  of  the  semitendinosus  is  changed  to  an 


Fig.   216. — Lateral  view  of  inlay  graft  in  place,  which  was  formed  from  the  bone  wedge 
removed  for  straightening  the  ankylosed  leg.      (See  Figs.  213-215.) 


anterior  insertion,  in  order  to  bring  about  more  stability  to  the 
limb;  but  as  this  treatise  does  not  deal  with  operative  pro- 
cedures other  than  bone  surgery,  the  reader  is  referred  elsewhere 
for  information  on  muscle  transference. 

The  comparative  advantages  and  disadvantages  of  brace 
and  operative  treatment  should  be  impartially  presented  to  the 
patient  or  his  parents.  The  only  advantage  in  the  use  of  braces 
for  such  a  disability  is  in  allowing  motion  of  the  knee.  The  ad- 
vantages of  a  stiff' ening  operation  of  the  knee-joint  are  the 
avoidance  of  constant  dependence  on  braces,  the  prevention  of 
deformities,  and  the  production  of  a  stable  limb. 


292  BONE-GRAFT    SURGERY 

As  there  is  always  an  undue  laxity  of  the  knee-joint  in  these 
infantile  cases,  it  is  not  advisable  to  do  a  simple  arthrodesis 
or  excision  of  the  joint,  as  bony  ankylosis  by  these  methods  is 
very   uncertain.      A    method    adopted    by    Hibbs,    which    has 


Fig.  217. — Rontgenogram  of  an  aithrodcf^is  of  the  knee-joint  with  the  patella 
enucleated  and  inlaid  as  the  arrows  indicate  to  aid  in  the  union  of  the  femur  to  the  tibia. 
Note  the  good  alignment  of  tibia  and  femur. 

proved  satisfactory,  is  to  use  the  patella  in  toto  as  a  bone  graft, 
inserted  between  the  apposed  femoral  and  tibial  ends  after  de- 
nuding the  patella  and  the  surfaces  of  the  femur  and  tibia  with 
which  it  is  to  be  contacted.  By  using  the  patella  fitted  into 
suitable  concavities  fashioned  in  the  denuded  articular  surfaces 


THE    INLAY   BONE    GRAFT  293 

of  the  head  of  the  tibia  and  the  condyles  of  the  femur,  the  slack 
of  the  lateral  ligaments  of  the  joint  is  taken  up  and  the  joint  is 
stiffened  by  its  ankylosis  through  the  patella.  In  performing 
this  technique,  it  is  always  advisable  to  remove  all  accessible 
articular  cartilage  and  synovial  membrane.  The  joint  must 
be  rigid  after  the  patellar  graft  is  inserted,  and  the  limb  brought 
to  10  to  15  degrees  of  flexion. 

The  approach  to  the  joint  is  usually  made  best  by  the  custom- 
ary U-shaped  skin  incision,  and  the  parts  are  closed  in  the  usual 
way.  A  long  fixation  plaster-of-Paris  spica  dressing  is  necessary, 
reaching  from  the  toes  to  and  including  the  pelvis,  to  insure 
perfect  fixation  of  the  joint  and  prevent  dislodgment  of  the 
patellar  graft,  which  may  be  held  in  place  between  the  ends  of 
the  femur  and  tibia  by  the  cup-shaped  concavities  formed  in 
these  bones  to  receive  it,  or  it  may  be  held  against  these  bone 
ends  by  suture  material. 

Technique  of  the  Author's  Bone -graft  Inlays  for  Ankylosing 
the  Paralytic  Knee. — This  method  of  stiffening  the  knee-joint 
is  that  previously  described  in  the  fixation  of  this  joint  in  adult 
tuberculosis,  and  has  been  found  to  be  extremely  satisfactory 
from  every  point  of  view.  It  is  rendered  very  simple  and 
accurate  and  is  rapidly  done  when  the  author's  motor-driven 
outfit  is  employed. 

In  this  connection  a  striking  example  is  herewith  cited,  em- 
phasizing the  importance  of  accuracy  of  technique  and  the  ad- 
vantage of  using  the  inlay-graft  method.  A  child  14  years 
of  age  was  brought  to  the  author,  having  suffered  an  attack 
of  infantile  paralysis  in  early  childhood,  which  left  the  lower 
limbs  markedly  paralyzed.  The  patient  had  had  both  knees 
operated  upon  in  Russia  when  he  was  10  years  of  age.  At  the 
time  the  author  saw  the  case,  both  knees  were  stiff  and  flexed 
at  an  angle  of  90  degrees.  Rontgenograms  showed  bony  union 
at  this  angle  and  also  the  embedded  broken  wire  with  which 
the  excised  joints  had  presumably  been  fastened.  The  ac- 
companying illustrations  of  this  case  add  another  to  the  many 
failures  to  produce  a  satisfactory  result  by  using  wire  to  se- 


294 


BONE-GRAFT   SURGERY 


cure  fixation  for  bony  union.  Tiie  patella  was  disregarded  and 
left  as  seen  in  the  Rontgenogram.  It  was  valuable  fixation 
and  osteogenetic  material  which,  if  used  as  inlays,  would  have 


Fig.  218. — This  is  a  case  of  arthrodesis  of  the  knee  for  paralysis,  done  in  Warsaw, 
Russia.  Two  strands  of  silver  wire  were  inserted  both  of  which  broke,  allowing  the  knee 
to  flex  to  nearly  a  right  angle  before  bony  union  occurred.  If  the  patella  had  been  used 
as  an  inlay  to  hasten  union,  it  is  very  probable  that  this  deformity  would  not  have 
occurred. 


undoubtedly  contributed  to  immediate  bony  union  and  avoided 
the  angulation. 

The  case  was  operated  upon  by  the  author.     The  joint  areas 


THE    INLAY   BONE    GRAFT 


295 


were  exposed  through  the  usual  U-shaped  incision;  the  overlying 
soft  parts  were  dissected  up;  the  patella  was  dissected  out  and 
placed  in  sterile  normal  saline  solution  until  the  deformity  was 
corrected  and  the  gutter  bed  prepared.     A  wedge-shaped  sec- 


FiG.  219. — Same  case  as  Fig.  218  after  removal  of  the  silver  wire  and  the  insertion  of 
the  patella  as  an  inlay.     Firm  union  occurred  in  5  weeks  after  this  operation. 


tion  of  bone,  with  the  base  forward,  was  removed  from  the 
region  of  the  angular  bony  ankylosis.  This  wedge  was  made  of 
such  a  size  that  when  it  was  removed  and  the  cut  surfaces  of  the 
femur  and  tibiaj^rought  together,  these  bones  were  in  a  position 


29()  BONE-GRAFT    SURGERY 

of  10  to  15  degrees  flexion  to  each  other.  A  guide  to  determining 
the  plane  of  these  saw-cuts  is  that  they  should  be  approxi- 
mately at  right  angles  with  the  femur  and  tibia,  respectively. 
The  twin  saw^  was  adjusted  so  as  to  fashion  as  wide  an  inlay 
as  possible  from  the  patella  and  at  the  same  time  utilize  its  full 
length.  With  this  adjustment  of  the  twin  saw  undisturbed, 
and  with  the  liml)  held  so  that  the  cut  surfaces  of  the  femur 
and  tibia  were  properly  approximated,  a  broad  gutter  of  the 
length  of  the  patellar  inlay  was  made  in  the  midline  on  the 
anterior  surfaces  of  the  tibia  and  femur,  one-half  of  the  gutter 
in  each.  The  strip  of  bone  between  these  saw-cuts  was  cut  across 
in  both  the  femur  and  the  tibia,  with  a  small  motor  saw.  These 
strips  of  bone  were  removed,  while  the  leg  was  flexed,  by  a  nar- 
row osteotome  cutting  lengthwise  in  the  bones.  With  the  tibia 
and  femur  again  brought  into  their  proper  position,  holes  were 
drilled  on  either  side  of  the  gutter.  Kangaroo  tendon  was 
threaded  into  them  and  the  patella  inlay  was  placed  in  position, 
and  the  sutures  tied  over  it.  The  subcutaneous  structures  were 
drawn  over  the  bone  and  sutured  with  chromic  catgut.  The 
skin  wound  was  closed  by  a  continuous  mattress  suture  of  plain 
catgut,  without  drainage.  A  plaster-of-Paris  case  was  applied 
from  the  toes  to  the  groin,  and  the  patient  was  placed  in  bed  with 
the  limb  elevated  on  an  incline,  to  relieve  pain  and  lessen  the 
tendency  of  oedema  of  the  foot  and  leg.  The  first  plaster  splint 
was  left  on  for  5  weeks,  at  the  end  of  which  time  there  was  firm 
union.  The  patient  was  allowed  up  and  about  with  the  aid 
of  crutches  at  the  end  of  4  weeks.  The  second  plaster  splint  was 
kept  on  for  6  weeks. 

This  method  is  also  applicable  to  Charcot's  knee,  if  the  tibial 
grafts  are  made  to  reach  well  beyond  the  affected  bone  area. 

HABITUAL  DISLOCATION  OF  THE  PATELLA 

The  usual  direction  of  congenital  or  habitual  dislocation  of 
the  patella  is  outward,  and  the  external  condyle  is  often  found  to 
be  on  a  horizontal  plane  relatively  much  below  that  of  the 
internal  condyle,  thus  giving  the  appearance  of  rotation  of  the 


THE    INLAY   BONE    GRAFT  297 

lower  end  of  the  femur,  so  that  the  external  condyle  is  farther 
back  and  the  internal  condyle  farther  forward  than  is  normal. 
When  the  leg  is  extended,  the  patella  usually  takes  its  normal 
position  between  the  condyles,  but  upon  flexion  is  found  to  be 
displaced  outward  and  even  to  He  over  the  external  condyle  or 
somewhat  external  to  it. 

Various  methods  have  been  devised  to  correct  this  displace- 
ment, but  of  the  procedures  which  have  been  practised  those 
where  correction  was  attempted  by  using  the  soft  tissues  have 
been  far  less  successful  in  securing  permanent  control  than  those 
where  the  control  was  attempted  by  furnishing  bony  obstruction 
to  redislocation. 

Krogius  {Zentralbl.  f.  Chir.,  March  5,  1904)  reports  two  cases 
(one  double)  in  which  it  was  evident  that  the  patella  was  drawn 
outward  by  the  tense  outer  portion  of  the  capsule  against  which 
the  relaxed  and  stretched  inner  portion  offered  but  weak  resist- 
ance. He  devised  the  following  operation  for  controlling  the 
displacement: 

The  first  step  is  the  approach  to  the  knee  by  Kocher's  incision. 
Second,  an  incision  is  made  extending  from  shghtly  above  the 
patella  down  a  few  inches  in  front  of  its  outer  edge  to  the  in- 
sertion of  the  ligamentum  patellae  through  the  ilio-tibial  band, 
tendinous  expansion  of  the  vastus  externus,  and  fibrous  capsular 
wall.  Third,  the  formation  of  a  bridge-shaped  flap  on  the  inner 
side  of  the  patella,  connecting  below  with  the  tendinous  expan- 
sion of  the  vastus  internus,  and  fibrous  capsule,  and  above  with 
muscle  and  fascia.  Fourth,  the  transplantation  of  the  flap, 
left  attached  at  both  sides,  across  the  patella  into  the  gap  at  its 
outer  edge. 

In  the  first  case,  after  6  months,  the  patella  again  began  to 
slip  outward,  although  complete  dislocation  did  not  occur.  In 
the  second  case,  the  result  was  perfect  after  3  months. 

Whitlock,  in  the  British  Surgical  Journal,  July,  1914,  states: 
''Outward  luxation  of  the  patella  may  be  the  result  of  direct 
violence  applied  to  the  inner  edge  of  the  patella,  but  quite  as 
often  follows  sudden  muscular  action." 


298  BONE-GRAFT    SURGERY 

Knock-knee,  undue  laxity  of  the  ligaments,  especially  of  the 
capsular,  and  more  particularly  a  deficiency  of  the  external 
lateral  ridge  of  the  external  condyle,  all  predispose  not  only  to 
the  occurrence  but  to  the  recurrence  of  the  disability.  A  sudden 
muscular  contraction  with  the  leg  extended  or  in  mid-flexion, 
especially  if  the  knee  is  inverted  and  the  foot  and  leg  are  everted, 
is  sufficient  cause  to  produce  displacement.  Eversion  of  the 
leg  brings  the  insertion  of  the  ligament  further  out  and  affords 
a  straighter  pull  for  the  extensor  muscles.  Reduction  is  gen- 
erally easy. 

The  advice  of  the  text-books  is  to  extend  the  knee,  fully  flex 
the  thigh  to  relax  the  rectus,  manipulate  the  knee-cap  by  push- 
ing it  medialward,  at  the  same  time  correcting  any  rotation. 
The  quadriceps  with  the  knee  extended  may  be  pulled  down  to 
aid  relaxation.  If  these  manipulations  fail,  they  may  often  be 
successful  with  the  joint  in  slight  flexion  instead  of  extension. 

Recurrence  may  happen  only  occasionally — usually  un- 
expectedly in  the  course  of  flexion — or  it  may  occur  very  fre- 
quently, the  patient  learning  to  replace  it  himself.  It  means, 
in  time,  a  relaxed,  weakened,  and  uncertain  joint.  The  recur- 
rence may  be  relieved  by  a  knee-cap  or  by  a  bandage.  As  a 
rule,  the  annoyance  is  so  great  that  something  more  radical 
must  be  done. 

One  operative  procedure  consists  in  reefing  the  medial  side 
of  the  capsule,  with  or  without  opening  the  joint.  Another 
consists  in  transplanting  the  insertion  of  the  patellar  ligament 
medialward.  These  operations  have  sometimes  been  per- 
formed with  good  results,  according  to  Whitlock,  but  he  offers 
as  a  third  method  that  of  reenforcing  the  patellar  ligament  by 
grafting  the  tendon  of  the  gracilis  into  it  (Tenney,  American 
Surgery,  1908,  xlviii,  7313). 

Dumferline,  in  Surgery,  Gyncecology,  and  Obstetrics,  April, 
1912,  describes  a  technique  which  he  has  used  successfully.  He 
takes  a  semilunar  flap  of  skin  and  fascia  from  the  medial  and 
posterior  surfaces  of  the  knee,  far  enough  back  to  enable  him 
to  reach  the  tendons  of  the  semitendinosus  muscle;  the  base  of 


THE    INLAY   BONE    GRAFT  299 

the  flap  crosses  the  hne  of  the  patella  and  the  patellar  ligament. 
The  semitendinosus  muscle  is  dissected  as  low  as  possible.     The 
patellar  ligament  is  spht,  a  portion  being  tm-ned  up  to  be  sutured 
to  the  cut  end  of  the  tendon  of  the  semitendinosus.     The  medial 
portion  of  the  capsule  and  the  fascia  are  then  plicated  with  several 
sutures,  chromic  catgut  being  used  for  both  tendon  and  capsule. 
Whitlock's  method  consists  of  turning  forward  a  long  horse- 
shoe-shaped flap  of  skin  and  fascia,  with  its  base  in  front  and 
its  apex  reaching  backward  to  the  hne  of  the  medial  ham-strings, 
the  base  corresponding  with  the  line  of  the  medial  margins  of 
the  patella  and  the  patellar  ligament.     The  ligamentum  patellse 
is  exposed  in  its  course  for  about  three-fourths  of  an  inch  by  divid- 
ing the  thin  capsular  fascia  overlapping  its  anterior  surface,  and  a 
thin  Kocher  fenestrated  blunt  dissector  is  thrust  through  the  liga- 
ment from  behind  forward  so  as  to  separate  the  fibres  as  near  its 
middle  as  possible,  making  a  space  of  half  an  inch  vertically. 
This  is  done  without  entering  the  general  synovial  cavity  of  the 
joint.     The  ligament  is  then  split  for  a  space  of  half  an  inch  or 
more  and  prepared  to  receive  the  end  of  the  gracilis  tendon. 
This  tendon  is  found  by  taking  the  sartorius  muscle  as  a  guide; 
the  fascial  attachment  of  the  sartorius  is  divided  above  and 
posteriorly  so  that  its  edge  may  be  thrown  forward.     The  slim 
tendon  of  the  gracihs  is  then  seen  lying  proximal  to  that  of  the 
semitendinosus,  and  parallel  with  it  are  some  vessels  and  a  nerve 
w^hich  should  be  avoided.     The  gracilis  tendon  is  isolated  and 
divided  as  near  its  tibial  attachment  as  possible.     It  is  brought 
forward   and   threaded   through   the  fenestrated   director   and 
passed  through  the  patellar  ligament,  and  is  sutured  with  chromic 
catgut.     Whitlock  states  that  the  gracilis  was  chosen  partly 
because  of  its  superficial  position  and  its  very  long  and  supple 
tendon,  but  mainly  because  it  is  primarily  an  adductor  in  its 
action  and  innervation,  being  supplied  by  the  obturator  nerve. 
It  is  a  less  important  flexor  of  the  knee  than  the  semitendinosus. 
The  altered  position  of  the  transplanted  tendon  acts  as  a  tie, 
fixing  the  ligamentum  patellse  and  preventing  the  passage  of  the 
patella   outward    during   full   extension  of  the  knee,  while  it 


300  b()ne-(;kaft  surgery 

tciuls  also  to  rotate  tli(^  joint  iu(Mlial\vai-(l.  In  cases  in  which 
there  is  a  lar<>;e  aniouiit  of  tlaccidit y  of  tlie  ('ai)sule  of  the  tendon, 
transplantation  is  foi-tifiecl  by  reefing  the  capsule. 

Gohlthwait  in  the  Arnerician  Journal  of  Orthopcrdic  Surgery, 
voL  i,  No.  3,  reports  11  cases  operated  upon  for  dislocation 
of  the  patella.  Through  a  5-in.  incision,  beginning  at  the  tuber- 
cle of  the  tibia,  the  patellar  tendon  was  exposed  and  split  into 
halves.  The  outer  half  was  freed  from  its  attachment  to  the 
tubercle  and  drawn  inward  under  the  remaining  half,  and  sutured 
securely  to  the  periosteum  together  with  the  expansion  of  the 
tendon  of  the  sartorius  muscle  at  the  inner  side  of  the  anterior 
surface  of  the  tibia.  A  number  of  these  cases  have  recurred 
after  this  operation. 

Murphy  ("The  Clinics,"  vol.  iii,  No.  4,  August,  1914)  reports 
his  method  of  dealing  with  congenital  luxation  of  the  patella, 
which  consists  of  exposing  the  joint  freely  through  two  longi- 
tudinal incisions,  one  on  each  side  of  the  patella,  and  turning  the 
patella  with  its  attached  ligamentum  patellae  to  one  side.  With 
a  broad  gauge  to  correspond  to  the  under  surface  of  the  patella, 
a  segment  of  bone  lying  between  the  condyles  is  removed  to 
deepen  this  intercondylar  groove.  A  flap  of  fascia  and  fat  is 
then  turned  in  from  above  and  sutured  over  this  denuded  bone 
area  to  prevent  ankylosis  of  the  patella  to  the  femur.  The 
patella  is  placed  in  position  resting  on  this  fascia  flap,  and  the 
inner  portion  of  the  fibrous  capsule  is  drawn  over  the  patella  and 
sutured  to  its  fibrous  covering. 

The  extent  of  trauma  to  the  joint  surfaces  would  indicate 
great  possibility  of  adhesions  and  limitation  of  joint  motion, 
and  the  absorption  of  the  fascia  fat  flap  covering  in  the  incised 
bone  area  would  also  tend  to  cause  adhesions  and  limitation 
of  joint  function. 

Graser  {Deutsche  Gesellschaft  /.  Chirurgie,  and  Zentralhl. 
f.  Chir.,  July  9,  1904)  presents  his  method,  and  reports  several 
cases  in  which  the  outer  condyle  of  the  femur  stood  considerably 
further  backward  than  the  inner  condyle  when  the  leg  was 
rotated  outward.     He  effected  a  cure  of  the  dislocation  by  per- 


THE    INLAY   BONE    GRAFT  301 

forming  a  supracondyloid  osteotomy  of  the  femur  and  twisting 
the  condyles  so  as  to  bring  the  outer  portion  forward  and  the 
inner  condyle  farther  backward.  This  procedure  carries  forward 
the  insertion  of  the  ligamentum  patellae  or  upper  end  of  tibia 
with  the  outer  condyle  of  the  femur,  and  thus  loses  much  of  its 
potency.  He  recommends  the  procedure  only  when  the  pos- 
terior position  of  the  outer  condyle  is  marked. 

The  Author's  Operation  for  Habitual  or  Congenital  Dislo- 
cation of  the  Patella. — From  the  multiplicity  of  methods 
devised  for  the  correction  of  this  deformity,  particularly  those 
procedures  having  to  do  with  the  soft  parts  as  a  means  for 
correction  of  dislocated  patellae,  also  from  the  case  reports 
following  such  operations,  it  can  be  safely  concluded  that  no 
method  has  proved  universally  satisfactory.  Many  of  the 
patelke  have  become  redisplaced  after  varying  periods  of  time 
following  soft-tissue  operations  for  fixation,  as  might  reasonably 
be  expected.  Grafted  soft  tissue,  whether  it  be  ligament,  or 
fascia,  will  withstand  but  little  strain  and  will  gradually  pull 
out  if  any  great  amount  of  traction  is  placed  upon  it.  The 
most  secure  anchorage  for  tendons,  fascia,  or  ligaments  is 
through  bone  structure,  and  even  then  unless  great  care  is 
exercised  and  the  ligament  itself  be  made  to  unite  with  the  bone 
to  which  it  is  secured,  independently  of  the  suturing  material,  one 
cannot  be  assured  that  the  new  anchorage  will  remain  secure. 
An}^  foreign  material  sutured  into  bone,  where  sufficient  strain 
is  placed  upon  it,  will  gradually  pull  through  by  its  own  destruc- 
tive action. 

On  account  of  the  failures  reported  by  the  various  operators 
using  different  methods,  the  author  has  devised  a  method  which, 
from  his  experience  with  its  use,  appeals  very  strongly  as  a  most 
rational  and  trustworthy  means  of  restoring  the  displaced 
patella  without  interfering  with  joint  function,  or  offering  any 
appreciable  chance  for  failure.  Instead  of  attempting  to  rectify 
the  deformity  by  a  complicated  procedure  or  subjecting  the 
joint  to  damage,  a  simple  change  of  the  architecture  of  the  outer 
condyle  of  the  femur  suffices. 


802 


BONE-GRAFT    SURGERY 


A  seiiiiluiiar  skin  incision  is  made  to  the  outer  side  of  the 
patella,  sufficiently  long  to  reach  below  the  tibial  tubercle  and  to 
above  the  external  condyle.  "Without  unduly  disturbing  the 
underlying  joint  structures,  the  external  condyle  is  incised  with 
a  broad  thin  osteotome  on  its  external  surface,  making  a  bone 
incision  of  from  I32  to  2  in,  in  length,  and  about  ]i  in.  below 
its  anterior  articulating  surface,  and  nearly  in  line  with  the  long 
axis  of  the  femur.  This  bone  incision  allows  the  anterior 
surface  of  the  external  condyle  to  be  raised  to  a  plane  above  the 
internal  condyle,  by  producing  a  greenstick  fracture  near  the 
intercondylar  groove,  the  object  being  to  place  a  permanent  and 


Fig.   220. — Luxated  patella  outward. 

rigid  obstacle  in  the  way  of  the  outward  displacement  of  the 
patella. 

When  the  anterior  segment  of  the  external  condyle  has  been 
pried  forward  sufficiently  to  demonstrate  its  obstructing  effect, 
the  width  of  the  bone  gap  thus  formed  is  measured  and  a  section 
of  bone  sufficiently  large  to  fill  this  cuneiform  gap  is  removed 
from  the  crest  of  the  tibia  through  the  lower  portion  of  the  same 
skin  wound  extended  below  the  tubercle.  This  bone-graft 
wedge  can  be  very  easily  and  quickly  procured  by  the  use  of  the 
motor  saw.  Before  the  graft  is  removed,  it  is  drilled  obliquely 
in  one  or  two  places  by  the  motor  drill,  so  that  it  may  be  pinned 
to  the  under  portion  of  the  external  condyle  when  put  into  its 


THE    INLAY   BONE    GRAFT 


303 


place.     Dowel  pins,  made  from  an  additional  portion  of  the  bone 
removed  from  the  crest  of  the  tibia  at  the  time  the  graft  is 


Fig.   221. — Patella  fixed  in  position  by  wedge  graft  under  external  condyle  and 

plicating  sutures. 


Fig.  222. — Author's  operation  for  outward  dislocation  of  the  patella,  showing  shape 
of  graft  in  position,  lifting  anterior  portion  of  external  condyle  to  block  the  recurrence 
of  the  dislocation. 


obtained,  and  rounded  by  the  motor  lathe  to  fit  the  drill  holes 
in  the  graft. 

The  cancellous  structure  of  the  condyle  receives  the  bone- 
graft  pins  easily  when  they  are  driven  into  place;  or  the  motor  drill 


304  BONE-GRAFT    SURGERY 

can  again  be  inserted  into  the  holes  ah-eady  niad(;  in  the  graft  and 
continue  them  into  the  external  condyle.  The  ligaments  and 
tendinous  expansions  are  sutured  o\'er  the  graft,  thus  holding 
the  lifted  portion  of  the  condyle  securely  by  kangaroo  tendon. 
The  skin  wound  is  closed  by  a  continuous  mattress  suture  of 
catgut,  without  drainage,  and  the  leg  up  to  the  groin  is  placed 
in  a  plaster-of-Paris  splint  for  three  weeks.  Passive  motion 
and  massage  are  begun. 

The  advantages  of  this  procedure  are  that,  with  no  sacrifice 
of  joint  cartilage,  a  minimum  of  joint  injury  is  produced  at  the 
time  of  operation,  thereby  greatly  lessening  the  chances  of 
limitation  of  motion  or  the  formation  of  adhesions,  and  that  the 
permanent  blocking  of  any  further  tendency  to  displacement 


Fig.  223. — A  indicates  the  normal  .size  and  anterior  prominence  of  the  external 
femoral  condyle.  B  indicates  the  flattened  external  condyle  with  a  consequent  luxa- 
tion of  the  patella  outward.  C  indicates  anterior  lifting  of  the  condyle  to  block  the 
recurrence  of  the  luxation  of  the  patella  with  the  wedge  graft  (dark  area)  in  position. 

of  the  patella  is  effected  by  the  actual  elevation  of  the  external 
condyle,  or  an  actual  restoration  of  the  normal  mechanico- 
anatomical  conditions.  The  soft  parts  are  not  interfered  with, 
and  the  only  further  suggestion  in  the  case  of  extremely  lax  and 
stretched  internal  capsular  ligaments  is  their  plication  with  kan- 
garoo tendon;  but  usually  this  is  unnecessary,  for  if  the  external 
condyle  is  propped  well  forward  it,  in  itself,  fulfils  all  requirements. 

GRAFTING    OF    AN    EPIPHYSIS    TO    STIMULATE    CONTINUOUS    BONE 
GROWTH  IN  AN  EPIPHYSIS  DAMAGED  BY  DISEASE 

Bond,  in  the  British  Journal  of  Surgery,  vol.  i,  p.  610, 
reports  an  interesting  case  of  a  child  4  years  of  age  who  had 
had  a  tuberculous  infection  of  the  inner  portion  of  the  upper 


THE    INLAY   BONE    GRAFT 


305 


epiphysis  of  the  left  tibia,  resulting  in  a  sharp  angular  bow-leg 
deformity  of  the  tibia,  following  the  cessation  of  the  tuberculous 
infection.  This  deformity  was  re- 
ported to  be  due  to  the  uninterrupted 
growth  of  the  fibula.  ''The  fibula 
was  divided  just  below  its  head  and 
this,  with  the  epiphysis,  w^as  removed. 
A  V-shaped  portion  of  bone  was  then 
removed  from  the  inner  side  of  the 
head  of  the  deformed  tibia  in  the 
situation  normally  of  its  epiphyseal 
junction.  The  deformity  was  cor- 
rected by  forcibly  straightening  the 
shaft  of  the  bone.  The  removed 
head  of  the  fibula  was  cut  down  to 
a  V  shape  and  inserted  into  the 
wedge-shaped  gap  in  the  head  of  the 
tibia.  In  this  way  a  piece  of  new 
and  growing  epiphyseal  cartilage  was 
introduced  into  the  inner  side  of  the 
head  of  the  tibia  in  the  situation  of 
the  damaged  epiphyseal  line." 


TRANSPLANTATION    OF   ENTIRE  JOINTS 

Deutschlander,  in  Deutsche  Zeit- 
schrift  f.  Chirurgie,  vol.  cxxviii,  1914, 
p.  183,  reports  a  case  of  transplanta- 
tion of  an  entire  knee-joint  of  a  4- 
y ear-old  boy  into  a  boy  13  years  of 


Fig.  224. — This  is  a  drawing 
illustrating  method  of  correction  of 
a  very  pronounced  bow  leg  from  an 
of  the 
upper         •     -    


age,  grafted  practically  in  its  entire   old  intraarticular  fracture 

upper  end  of  the  tibia.     An  osteo- 

extent,     including     the    joint    capsule     tomy  was  done  and  a  graft,  which 

1     ,1         .     .       T  ,  .  was  obtained  from  the  crest  of  the 

and  the  mterhgamentous  apparatus    tibia   lower   down  was  inserted. 

as  well  as  the  patella.       Although  the     ^  fixation  sutures  w^ere  necessary. 

^  *  The  operation  of  which   this  is  a 

result    fell   short   of  the   expectations,     drawing  was  done  in  March,  1912. 

the  healing  in  of  this  manifold  tissue  complex  was  associated 
with    a    series    of   very  interesting  processes,   well  worthy  of 

20 


3()()  BONE-GRAFT    SURGERY 

piil)li('ati()ii.  The  j^atient  was  improved  in  that  the  resulting 
sHghtly  movable  pscudarthrosis  was  preferable  to  the  bilateral 
bony  ankylosis  of  the  knees  which  had  existed  before  the  opera- 
tion. Transplantation  of  the  patella  was  made,  but  proved 
unsuccessful.  Rontgenograms  taken  20  days  after  operation 
showed  that  even  at  this  stage  no  trace  of  the  transplanted  pa- 
tella could  be  demonstrated. 

"The  probability  of  viable  transplantation  of  the  patella 
would  seem  to  be  extremely  slight.  The  articular  cartilage  was 
found  to  be  the  only  viable  element  in  the  transplantation  of 
entire  articular  segments.  It  apparently  possesses  a  great 
power  of  resistance  and  can  be  successfully  transplanted,  even 
under  unfavorable  conditions. 

"Taking  into  consideration  the  total  result  of  the  healing 
processes  in  this  case  of  an  entire  transplanted  knee-joint,  we 
find  that  the  larger  portion  of  the  transplanted  tissue  was 
destroyed  and  only  an  extremely  small  fraction  actually  healed 
in.  It  was  really  only  the  articular  cartilage  which  was  shown 
to  remain  viable  for  a  long  time,  although  not  without  a  very 
considerable  loss  of  cellular  material.  In  view  of  these  findings, 
it  is  advisable  to  abandon  the  transplantation  of  tissue  com- 
plexes, which  are  doomed  to  destruction,  as  a  rule.  The 
organism  will  thus  be  saved  an  amount  of  work  which  it  can 
more  profitably  employ  for  the  functional  development  of  the 
joint." 

Bone  Transplantation  in  a  Case  of  Sarcoma  of  the  Bone. — 
Schulze-Berge,  in  Ceniralblatt  fur  Chirurgie,  No.  48,  1913, 
records  the  case  of  a  patient,  a  woman,  26  years  of  age,  with  a 
spindle-cell  sarcoma  of  the  head  of  the  tibia.  As  no  fresh 
joint  was  available  for  transplantation,  the  writer  endeavored 
to  preserve  a  useful  leg,  though  abandoning  motility  in  the 
knee-joint.  After  resection  of  the  diseased  articular  end  of  the 
tibia  to  an  extent  of  about  8  cm.,  the  femoral  condyle  as  well  as 
the  head  of  the  fibula  was  freshened  and,  for  the  substitution 
of  the  tibia,  a  piece  of  the  fibula  of  the  healthy  side,  of  suitable 
length,  was  transplanted  into  the  tibia  as  well  as  into  the  femoral 


THE    INLAY   BONE    GRAFT  307 

condyle.  The  transplanted  bone  segment  healed  solidly  in 
place,  although  the  covering  of  the  soft  parts  could  not  be 
firmly  applied  around  the  transplanted  bone,  which  led  to 
suppuration. 

Rontgenograms  taken  1  year  later  showed  that  the  trans- 
planted bone  had  attained  the  strength  of  the  tibial  diaphysis 
by  periosteal  proliferation.  In  the  lower  half,  the  transplanted 
bone  had  disappeared  through  absorption;  while  in  the  upper 
half  it  still  remained  visible.  The  leg  was  solid,  except  possibly 
slight  motion  from  before  backward. 


CHAPTER  VII 

THE  BONE  GRAFT  IN  THE  TREATMENT  OF  DISEASES  AND 
DEFORMITIES  OF  THE  FOOT  AND  LEG 

CLUBFOOT.     AUTHOR'S  TECHNIQUE 

The  treatment  of  clubfoot  must  necessarily  take  into  con- 
sideration not  alone  the  age  of  the  patient  and  the  degree  of  the 
deformity  but  the  type  or  class  of  the  deformity  into  which  it 
can  be  subdivided  for  convenience,  so  far  as  treatment  is  con- 
cerned, i.e.,  (1)  those  cases  where  the  treatment  is  begun  in  early 
infancy  and  carried  to  complete  correction  by  manipulation  and 
external  fixation;  (2)  those  cases  where  early  treatment  has  been 
indifferently  cari-ied  out,  or  has  been  interrupted,  resulting  in 
partial  or  complete  relapse  of  deformity;  and  (3)  those  cases 
which  have  received  no  corrective  treatment  whatever. 

In  the  first  group  proper  manipulation  and  fixation  treat- 
ment is  all  sufficient  and  will  not  be  dealt  with  in  this  treatise. 
In  the  second  and  third  groups — the  relapsed  or  untreated  cases — 
bone  plastic  operations  are  recommended  only  beyond  infancy, 
where  the  tarsal  bones  have  partially  or  completely  ossified  and 
resist  remoulding  by  long-continued  manipulations  and  fixation 
in  over-correction.  Such  cases  have  been  made  to  yield  to  the 
varied  technique  herein  described  (Fig.  228). 

Group  II,  may  be  again  subdivided  into  tw^o  types  of  re- 
lapsed congenital  clubfoot,  viz.,  that  of  the  long,  comparatively 
slender,  foot  where  the  osseous  development  has  gone  so  far  as  to 
resist  correction  in  spite  of  the  tenotomy  of  the  tendo  Achillis 
to  overcome  equinus  and  forcible  stretching  followed  by  fixation 
in  plaster  of  Paris  or  braces,  and  with  still  gradually  relapsing 
forefoot,  particularly  toward  varus;  and  another  group  w^hich 
will  include  those  cases  of  relapsed  clubfoot  consisting  of  a  short 
chunky  foot  in  extreme  varus.     In  many  of  these  latter  cases  we 

308 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  309 

find  that  the  patient  has  by  the  impact  of  walking  produced 
an  hypertrophy  of  the  cuboid,  the  foot  being  so  markedly  in- 
verted and  supinated  that  the  weight  of  the  body  rests  directly 
upon  the  cuboid;  the  peroneal  muscles  from  long  disuse  are 
undeveloped  and  elongated,  and  the  dorsal  flexors  of  the  foot 
on  the  leg  are  shortened  and  act  as  direct  agents  to  increased 
varus  and  supination  of  the  foot. 

The  technique  of  the  operative  treatment  devised  and  applied 
by  the  author  for  dealing  with  the  first  subdivision  of  this  group 


Fig.  225. — Plantar  -view  of  a  clubfoot  showing  the  marked  adduction  of  forefoot, 
which  produces  the  concave  contour  or  short  inner  side  and  long  or  convex  outer  surface 
of  the  foot. 

The  author's  technique  for  this  type  of  foot,  in  older  children,  is  to  restore  perma- 
nently the  shape  of  the  foot  by  placing  a  bone  graft  into  the  skeleton  of  the  inner  side  of 
the  foot.  If  the  deformity  is  of  congenital  origin  the  graft  is  placed  into  the  split 
scaphoid  bone.  If  it  is  of  paralytic  origin,  with  conseciuent  instability,  the  graft  is 
placed  into  the  astragalo-scaphoid  joint.     (See  text.) 

of  relapsed  clubfoot,  namely,  the  long  slender  type  with  marked 
varus  and  moderate  adduction  of  the  forefoot,  but  without 
marked  hypertrophy  of  the  cuboid,  is  as  follows: 

The  deformed  foot,  and  the  leg  also,  having  been  prepared 
for  operation,  and  a  tourniquet  securely  applied  above  the 
knee,  the  equinus  is  first  corrected  by  tenotomizing  the  tendo 
Achillis,  to  enable  the  operator  to  force  the  foot  into  dorsal 
flexion  on  the  leg.  A  narrow  sharp  tenotome  is  thrust  through 
the  skin  with  its  blade  parallel  with  and  just  anterior  to  the 


310 


B()NE-(!I{AFT    SURGERY 


tendon,  and  about  tliroo-(iuai"iers  of  an  inch  above  its  insertion 
into  the  os  ealcis.  The  cutting;  edge  of  the  tenotome  is  turned 
})()st(M'i()i-]y  and  tli(^  Icndon  is  (H\'i(h'd  fi-oni  b('fore  backward, 
care  being  taken  to  divide  the  plantaris  tendon  as  well.  The 
division  is  easily  perceptible  in  the  sudden  giving  way  of  the 
resistance  to  dorsal  flexion  of  the  foot.  The  heel  is  brought 
down  thoroughly  by  forcible  dorso-flexing  of  the  forefoot. 

The  next  stoj^,  when  no  ti-uo  l)ono  ojieration  is  done,  is  the 
thorough  stretching  out   of  tlie  \'arus  by  mani])ulation — either 


1 


In 


Figs.  226  and  227. — Marked  untreated  clubfoot  of  a  boy  7  years  old.  Before 
operative  correction.  A  wedge-shaped  graft  was  removed  from  the  cuboid  bone  on 
outer  side  of  the  foot  and  placed  into  the  split  scaphoid  after  the  tendo  Achillis  and 
inner  portion  of  the  plantar  fascia  had  been  severed  and  foot  forcibly  corrected.  (See 
Figs.  228  and  229  for  result.) 


manual  or  with  the  Thomas  wrench — with  or  without  the 
wedge  block  as  a  fulcrum.  The  foot  is  then  so  lax  as  to  be  easily 
placed  in  an  over-corrected  position,  but  it  is  obvious  that  if 
reliance  is  placed  upon  external  correction  alone  relapse  would 
take  place.  This  is  very  prone  to  occur  following  the  Phelps 
operation  where  a  free  division  of  all  soft  structures  is  made 
down  to  the  bone  and  the  foot  forced  into  valgus,  leaving  the 
wide  gaping  wound  to  heal  by  granulation — resulting  in  a  con- 
tracting scar — and  the  articular  surfaces  of  the  tarsal  bones 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


311 


widely  separated  with  no  provision  made  to  prevent  these 
articulations  from  closing  up  again. 

.  -  Having  had  exceptional  clinical  opportunity  for  observing  a 
large  number  of  relapses  in  clubfeet  following  these  soft-tissue 
operations,  it  became  evident  to  the  author  that  if  relapse  was 
to  be  prevented  a  remodelling  of  the  tissues  or  bony  framework 
of  the  foot  was  essential.     All  previous  clubfoot  bone  operations 


Fig.   228.  Fig.   229. 

Figs.  228  and  229. — Same  case  as  Figs.  226  and  227  after  correction  of  clubfoot  deform- 
ity by  insertion  of  bone  graft. 

have  entailed  removal  of  wedges  of  bone  from  the  outer  or  long 
side  of  the  tarsus,  and  have  thus  still  further  shortened  an 
already  short  and  undeveloped  foot.  Since  the  trustworthiness 
of  the  bone  graft  had  been  so  thoroughly  proven,  it  occurred  to 
the  author  in  1911  that  the  surgeon  could  well  follow  carpentry 
methods  and  remodel  the  tarsus  by  elongating  the  concave  or 
short  inner  side  of  the  foot  by  placing  a  bone-wedge  graft  be- 


312  BONE-GRAFT   SURGERY 

between  the  split  halves  of  the  scaphoid  l)oiie.  At  tlie  same 
time,  that  this  i)(M-inaiieiitIy  corrects  the  houy  deformity  of  the 
foot  it  may  lengthen  it  sufficiently  to  avoid  mismated  shoes. 
Any  degree  of  lengthening  of  the  foot  is  far  preferable  to  any 
further  shortening  of  the  same. 

The  technique  of  the  operation  is  as  follows:  A  U-shaped 
skin  incision  is  made  on  the  inner  aspect  of  the  foot  and  the 
flap  with  its  subcutaneous  tissue  is  dissected  back,    exposing 


Fig.  230. — A  congenital  clubfoot  of  less  severe  type  of  deformity.  The  varus  is  not 
extreme  and  there  it  is  not  necessary  to  remove  bone  from  the  outer  side  of  the  foot.  A 
tibial  graft  is  placed  into  the  split  scaphoid  bone.      (See  Fig.  231.) 

the  scaphoid  bone.  The  apex  of  this  incision  should  extend 
well  forward  in  the  region  of  the  great  toe;  or  a  straight  incision 
may  be  made  over  and  parallel  with  the  long  axis  of  the  dorsum 
of  the  foot  so  that  the  superior  surface  of  the  scaphoid  is  ap- 
proached. Whatever  incision  is  employed,  however,  it  should 
always  be  so  situated  that  when  the  wound  is  closed  the  skin 
sutures  do  not  come  over  the  graft.  The  development  of  the  field 
of  the  bone  operation  should  be  carefully  done,  as  the  changed 
bone  formation  and  landmarks  may  be  extremely  distorted. 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  313 

With  a  half-inch,  thin  and  sharp  osteotome,  the  scaphoid  is 
split  into  anterior  and  posterior  halves,  either  by  a  linear 
osteotomy  through  the  long  axis  or  by  a  curved  bone  incision 
from  above  following  the  general  curved  contour  of  the  bone. 
The  foot  is  then  forced  into  the  required  degree  of  over-correction, 
and  the  gap  between  the  halves  is  widened.  All  resistance  by 
plantar  fascia  or  other  tissues  is  relieved  by  severing  the  struc- 
tures with  a  scalpel  through  the  wound  already  made,  or  by 
means  of  subcutaneous  fasciotomy  through  an  additional  teno- 
tome wound.     The  width  of  the  gap  is  taken  with  calipers,  as 


Fig.  231. — Same  as  Fig.  230  after  operative  correction  and  insertion  of  graft. 


a  measurement  for  the  size  of  the  bone  wedge  to  be  obtained 
preferably  from  the  tibia  of  the  same  limb.  The  skin  and  sub- 
cutaneous structures  overlying  the  anterior  internal  aspect  of 
the  tibia  are  incised  at  about  the  junction  of  the  middle  and  lower 
thirds  of  the  shaft,  which  region  is  selected  as  it  yields  a  denser 
and  thicker  bone  cortex  than  higher  up.  The  skin  incision 
should  be  situated  so  that  it  does  not  overlie  the  cavity  from 
which  the  graft  is  removed. 

Having  freed  the  crest  from  muscle  attachment,  and  with 
the  skin  and  soft  parts  well  retracted  by  sharp  retractors,  the 


314 


BONE-GRAFT    SURGERY 


width  aiul  Ihickucss  of  the  required  wedge  is  iiiiirked  off  by  a 
scalpel,  cutting  into  the  periosteum. 

The  niotoi-  saw  is  tluMi  enii)l()ye(l  to  cut  the  wedge  graft 
from  the  tibia.  The  two  cuts  are  made  transversely  through 
the  cortex  of  the  crest  at  the  measured  distance  apart,  and  are 
caused  to  converge  to  each  other  as  the  medullary  cavity  is 
approached. 

Before  its  dislodgment  from  the  tibia,  the  graft  is  drilled 


Fig.  232.  Fig.  233. 

Figs.  232  and  233. — Before  and  after  operation.      Congenital  clubfoot  of  same  type  and 

treated  by  same  method  as  (Figs.  226  to  229). 

with  the  small  motor  drill  through  the  centre  of  its  cortex  for 
retaining  sutures,  and  is  then  removed  from  its  bed  with  the 
aid  of  a  sharp  osteotome,  and  either  placed  in  normal  saline 
solution  until  used,  or  transferred  directly  to  its  position 
between  the  halves  of  the  split  scaphoid.  It  should  fit  so  tightly 
as  to  prevent  any  return  to  varus  and  adduction  deformity  when 
the  forefoot  is  released  by  the  assistant. 

If  the  cortex  of  the  scaphoid  is  too  dense  to  permit  the 
passage  of  a  short  strong  curved  cervix  needle,  the  edges  of  the 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  315 

scaphoid  halves  are  drilled  with  the  motor  drill.  Ordinarily, 
in  children,  the  scaphoid  edges  readily  permit  puncture  by  the 
cervix  needle.  The  technique  is  carried  out  as  follows,  in  either 
case:  The  kangaroo  tendon  is  threaded  through  the  drill  holes 
of  the  graft  wedge,  which  is  readily  done  on  account  of  the  stiff- 
ness of  the  tendon.  With  the  graft  in  the  centre  of  the  tendon 
strand,  a  cervix  needle  is  threaded  to  each  end.  These  needles 
are  thrust  through  the  scaphoid  edges  from  the  cut-surface  side, 


Fig.  234. — -Diagram  illustrating  an  inlay-wedge  bone  graft  removed  from  the  crest  of 
the  tibia  or  the  cuboid  of  the  other  side  of  the  foot  and  placed  into  the  split  scaphoid  for 
the  purpose  of  permanently  remodelling  the  tarsus  of  a  congenital  clubfoot.  In  this 
deformity  the  inner  side  of  the  tarsus  is  shorter  than  its  outer  side,  and  the  graft  is 
inserted  to  overcome  this  distortion  in  older  children  and  adults.  The  advantage  of 
guarding  against  relapse  by  remodelling  the  bony  tarsus  is  also  augmented  bj^  lengthen- 
ing the  foot,  which  is  always  short. 

either  through  the  drill  holes  in  the  edges  or  through  holes 
made  by  the  needles  themselves.  The  bone-graft  wedge  is 
then  forced  into  place  between  these  scaphoid  halves,  the  tendon 
is  drawn  taut,  and  tied  over  the  graft.  The  subcutaneous 
structures  are  then  drawn  together  over  the  grafted  area  and 
the  skin  flap  is  closed  over  all  by  plain  catgut  without  drainage. 
If  the  deformity  is  a  severe  one  and  the  skin  wound  cannot  be 
closed  without  too  great  tension  and  danger  of  slough,  it  is  best 


316 


BONE-GRAFT   SURGERY 


not  to  ;itt(Mni)t  to  approximate  the  flai)s  by  loo  si'f'at  tension, 
but  if  a  skin  <»;a])  is  necessitated  it  should  be  as  far  from  the 
graft  as  possible,  and  will  readily  granulate  over. 

The  dressings  are  then  applied.  Cotton  is  placed  between 
the  toes  to  take  up  secretion;  the  foot  and  leg,  to  above  the 
knee,   are  covered  with   a   Shaker-flannel    bandage   or    sheet 


Fig.  235.  Fig.  236. 

Fig.  235. — A  marked  case  of  paralytic  equiiio  varus.  The  lateral  deformity  was 
corrected  and  maintained  by  placing  a  tibia  graft  into  the  astragalo-scaphoid  joint, 
after  the  bones  forming  that  joint  has  been  separated  by  the  correction  of  the  deformity. 

Fig.  236. — ^Photograph  of  case  (Fig.  235)  after  correction  of  deformity.  A,  indi- 
cates location  in  tibia  from  where  the  graft  was  obtained. 


wadding,  as  a  lining  to  the  plaster-of-Paris  fixation  dressing 
wdiich  is  next  applied  with  the  foot  held  in  slight  over-correction 
and  the  knee  flexed  nearly  to  a  right  angle.  The  knee  is 
flexed  to  this  angle  in  order  to  afford  a  leverage  action  against 
the  tendency  of  relapse  of  the  forefoot.  This  plaster  dressing 
should  remain  in  place  for  4  to  6  weeks,  when   that  portion 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


317 


above  the  flexed  knee  is  cut  off,  the  remainder  of  the  dressing 
being  left  in  place  for  4  to  6  weeks  longer,  when  the  entire 
protective  dressing  is  removed  and  massage  and  exercise  of  the 
foot  and  leg  is  instituted. 

Should  it  be  deemed  advisable  for  the  comfort  of  the  patient 
or  as  a  means  of  maintaining  the  protective  fixation  for  a  longer 


Fig.  237,  Fig.  238. 

Figs.  237  and  238. — Illustrate  method  of  applying  plaster-of-Paris  dressing  for  club- 
feet. The  knee  is  flexed  to  a  right  angle  and  the  thigh  is  used  as  lever  to  prevent  the 
relapse  of  the  adduction  deformity  of  the  forefoot. 

period,  the  simple  clubfoot  sling  support  is  the  most  serviceable 
form  of  brace  to  be  applied.  It  consists  of  a  strip  of  canton 
flannel  folded  upon  itself  four  to  six  times,  making  a  flannel  strip 
three-quarters  of  an  inch  to  an  inch  wide,  and  long  enough  to 
encircle  the  ankle  and  pass  down  under  the  foot  and  up  to  the 
external  malleolus;  to  the  ends  of  the  strip  a  strong  webbing 
strap  is  sewed,  which  extends  up  the  outside  of  the  leg  to  below 


318  BONE-GRAFT   SURGERY 

the  head  of  the  fibula,  where  it  buckles  to  the  upper  end  of  a 
steel  upright  which  is  fastened  about  the  upper  part  of  the  calf 
by  a  strap  and  to  the  shoe  below,  between  the  heel  and  the  sole. 
This  steel  upright  has  a  simple;  joint  at  the  ankle,  or,  if  there  is 
still  a  need  for  preventing  the  tendency  to  equinus  of  the  foot,  a 
catch  can  be  arranged  at  the  joint  to  stop  extension  beyond  a 
right  angle.  The  ]:)ull  of  this  sling  with  each  step  is  sufficient 
to  hold  the  foot  in  abduction  and  prevent  varus.  A  less  efficient 
brace  is  that  with  an  inner  single  bar  and  straps  about  the  ankle. 

The  technique  of  the  operative  treatment  devised  by  the 
author  for  dealing  with  the  second  subdivision  of  this  group  of 
relapsed  clubfoot,  namely,  those  cases  with  a  short  chunky 
foot  in  extreme  varus  with  the  cuboid  so  hypertrophied  and 
malformed  as  to  resist  any  reasonable  attempt  at  forcible 
correction  of  the  foot,  even  after  the  scaphoid  is  split,  is  some- 
what difTerent.  To  these  cases,  the  author  applies  the  bone- 
graft  wedge  between  the  halves  of  the  scaphoid  split 
transversely  across  the  foot,  precisely  as  in  the  technique  just 
described,  with  the  exception  that  the  bone  wedge  is  removed 
from  the  body  of  the  hypertrophied  cuboid,  instead  of  from 
the  crest  of  the  tibia,  and  inserted  between  the  halves  of  the 
split  scaphoid. 

The  technique  of  the  removal  of  the  cuboid  wedge  is  as 
follows :  A  skin  incision  is  made  through  the  calloused  skin  and 
subcutaneous  tissue,  down  to  the  cuboid  along  the  outer  border 
of  the  foot,  sufficiently  long  to  give  a  good  exposure  of  this 
bone.  Having  previously  determined  with  the  calipers  the 
approximate  thickness  of  the  wedge  desired — this  wedge  is  out- 
lined with  the  scalpel — cutting  through  the  periosteum  trans- 
versely to  the  long  axis  of  the  foot,  being  careful  to  remove  a 
wedge  of  sufficient  width  to  allow"  full  over-correction  of  the 
foot.  With  the  motor  saw  the  bone  is  then  cut  following  the 
periosteal  incisions;  the  planes  are  made  to  converge  slightly, 
and  as  the  entire  division  of  the  bone  cannot  be  safely  made 
with  the  motor  saw,  the  bone  incision  is  completed  by  a  thin 
sharp  osteotome  driven  into  the  saw-cuts.     Before  dislodging 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  319 

the  wedge  from  the  cuboid,  it  is  drilled  at  its  centre  for  the 
passage  of  the  kangaroo  fixation  suture.  Then  with  curved 
scissors  the  soft  tissues  still  holding  the  graft  are  freed  and  the 
wedge  is  removed,  to  be  placed  immediately  in  normal  saline 
solution  or  directly  into  its  position  between  the  split  halves  of 
the  scaphoid. 

The  foot  is  thus  di\'ided  transversely  through  its  entire 
tarsal  structure,  which  allows  the  forefoot  not  only  to  be  swung 
outward  at  this  point  but  to  be  rotated  about  the  cubo-scaphoid 
ligament;  thus,  at  the  same  time,  both  adduction  and  varus 
are  corrected.  As  this  ligament  lies  approximately  equidistant 
from  the  inner  border  of  the  scaphoid  and  the  outer  border  of 
the  cuboid,  it  is  the  centre  of  a  circle  of  which  a  wedge  taken 
from  the  cuboid  is  a  sector,  and  when  used  to  fill  the  gap  formed 
by  splitting  the  scaphoid  and  correcting  the  foot,  it  exactly 
fits  and  at  the  same  time  the  gap  formed  by  its  removal  from  the 
cuboid  is  necessarily  closed. 

The  foot  and  limb  are  included  in  a  plaster-of-Paris  dressing, 
from  the  toes  to  above  the  knee,  with  the  foot  well  over-corrected 
and  the  knee  flexed.  This  dressing  should  remain  on  the  limb 
for  8  weeks,  followed  by  a  second  plaster-of-Paris  dressing  up 
to  the  knee  which  should  remain  on  for  4  weeks. 

Advantages  of  the  bone  graft  in  clubfoot:  (1)  It  lengthens  an 
alread}'  much  shortened  foot.  (2)  It  permanently  lengthens  the 
short  side  of  the  skeleton  of  the  foot  and  insures  in  a  most 
trustworthy  way  against  a  relapse  of  the  deformity.  (3)  No 
joint  is  in\'olved  by  the  operation,  therefore  there  is  no  inter- 
ference with  joint  function  or  mobility.  (4)  It  furnishes  a 
means  for  permanently  correcting  the  severest  types  of  club- 
foot, even  in  the  adult. 

ACQUIRED  CLUBFOOT 

Paralytic  Equine  Varus. — This  type  of  clubfoot  is  usuallj^ 
due  to  an  attack  of  anterior  polyomyelitis  (infantile  paralysis), 
and  is  caused  by  either  partial  or  complete  paralysis  of  the 
peroneal  muscles,  producing  an  unbalanced  condition  of  muscle 


320  BONE-GRAFT    SURGERY 

control  of  the  foot.  This  results  in  a  deformity  similar  to  that 
of  congenital  clubfoot.  The  outer  border  of  the  foot  drops, 
the  forefoot  adducts  and  the  ])atient  walks  on  the  outer  aspect 
of  the  foot,  causing  it  to  fuillier  adduct  by  weight  bearing. 
An  undue  laxity  of  the  astragalo-scaphoid  articulation  results, 
and  the  unopposed  muscle  action  of  the  anterior  and  posterior 
tibial  muscles  pulls  the  foot  further  into  varus  and  adduction. 


Fig.  239. — To  illustrate  weight-bearing  of  a  paralytic  clubfoot.     The  peroneal  muscles 
were  entirely  paralyzed  in  this  case. 

The  pull  of  the  anterior  tibial  muscle,  when  the  foot  is  in  full 
adduction,  forces  the  foot  into  further  varus  and  adduction 
on  the  leg,  and  cases  have  been  seen  where  the  forefoot  is  so 
markedly  adducted  and  inverted  upon  the  leg  that  the  patient 
w^alks  wholly  upon  the  outer  side  of  the  os  calcis  and  cuboid 
bones.  The  forefoot  in  the  more  severe  cases  is  limp  and  hardly 
touches  the  ground,  and  there  is  sharp  angulation  at  the  medio- 
tarsal  joint. 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


321 


This  type  of  clubfoot  presents  four  principal  defects,  namely: 
(1)  equinus  resulting  from  the  shortened  calf  muscles;  (2)  lack 
of  support  of  the  outer  border  of  the  foot;  (3)  abnormal  laxity 
of  the  astragalo-scaphoid  articulation;  and  (4)  misplaced  centre 


Fig.  240. — Drawing  of  paralytic  clubfoot  .showing  turning  out  of  the  patella,  adduction 
and  varu.s  deformity  of  the  foot,  largely  from  paralysis  of  the  peroneal  muscles. 

of  weight  bearing  in  the  foot,  due  to  its  faulty  adducted  varus 
position. 

These  faulty  mechanical  conditions  are  best  met  by  the 
following  measures.  The  leg  and  foot  having  been  prepared 
for  operation,  and  a  tourniquet  applied  above  the  knee,  the 
equinus  is  overcome   by  the   subcutaneous    tenotomy    of    the 

21 


322 


BONE-GRAFT   SURGERY 


tendo  Achillis,  uiid  the  heel  is  brought  well  down  ])y  forcible 
manipulation. 

The  astragalo-scaphoid  joint  is  reached  by  a  U-shaped  in- 


FiG.   241. — Curved  skin  incision  for  the  purpose  of  furnishing  a  skin  flap  so  skin  sutures 
will  not  come  over  the  graft.    " 


cision,  precisely  as  described  for  congenital  clubfoot.  The 
curved  part  of  this  skin  incision  should  be  well  forward  so  as 
to  afford  an  ample  flap  to  cover  in  the  grafted  field.    If  preferred, 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


323 


the  joint  may  be  exposed  by  a  straight  incision,  parallel  with 
the  anterior  tibial  tendon  on  the  dorsum  of  the  foot. 

The  articulating  surfaces  of  the  head  of  the  astragalus  and 
scaphoid  are  removed  with  a  narrow  osteotome  and  mallet, 
following  the  contour  of  the  joint  or  forming  plane  surfaces, 
as  may  appear  better  adapted  to  the  individual  case  at  the  time 


Fig.  242. — Method  of  applying  manual  force  in  correcting  clubfoot. 


of  operation,  the  idea  being  to  secure  the  maximum  amount 
of  bone  surface  for  contact  with  the  graft. 

If  over-correction  of  the  foot  is  resisted  by  the  soft  structures, 
they  are  subcutaneously  severed. 

The  over-correction  of  the  foot  produces  a  wedge-shaped 
cavity  between  the  separated  cut  surfaces  of  the  head  of  the 
astragalus  and  scaphoid.  This  wound  is  packed  with  a  hot 
saline  compress. 

To  overcome  the  dropping  of  the  outer  border  of  the  foot. 


324 


BONE-GRAFT   SURGERY 


due  to  the  paralysis  of  the  peroneal  muscles,  the  tendons  of 
these  muscles  are  made  to  serve  as  ligaments  (Codi villa,  Gallie), 


Fig.   243. — -Wedge  graft  in  place  for  paralytic  clubfoot. 


the  external  malleolus  and  tendons  are  exposed  by  a  curved 
skin  incision  encircling  the  lower  end  of  the  malleolus. 


Fig.   244. — Routgenogram  of  graft  in  place  6  months  after  operation  for 
paralytic  clubfoot. 


An  osteoperiosteal  flap  with  its  overlying  periosseous  tissues 
is  lifted  from  the  external  malleolus  and  turned  posteriorly  on 
the  periosseous  tissues  as  a  hinge.     The  osseous  incisions  for 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


325 


forming  this  trap-door  are  easily  and  quickly  made  with  the 
author's  small  motor  saw,  and  further  freeing  of  this  flap  is 
accomplished  by  a  sharp  osteotome.  The  peroneal  tendon 
sheaths  are  split  and  the  tendons  are  freed  and  placed  under 
this  osteoperiosteal  trap-door. 

The  foot  is  then  forced  into  pronation  and  the  peroneal 


Fig.  245.  Fig.  246. 

Figs.  245  and  246. — Before  and  after  operative  correction,  paralytic  clubfoot  (Talipes 
equino  varus)  from  infantile  paralysis  and  loss  of  power  in  the  peroneal  muscle.  A 
bone  graft  obtained  from  opposite  tibia  at  A  was  mortised  into  the  head  of  the  astrag- 
alus and  the  scaphoid  after  correction  of  the  deformity  of  the  foot.  The  peroneus, 
longus  and  brevis  tendons  were  anchored  into  the  external  malleolus  as  ligaments. 
For  rontgenogram  see  Fig.  247. 


tendons  are  drawn  taut  by  reefing  or  suturing  them  securely 
to  the  periosseous  tissues  above  this  bone  flap. 

The  edges  of  this  osseous  flap,  as  well  as  the  adjacent  cor- 
tex, are  drilled,  the  tendons  fitted  into  the  grooves,  and  the  trap- 
door is  closed  over  and  held  firmly  in  place  by  kangaroo-tendon 
sutures  passed  through  the  drill  holes  and  tied. 


326 


BONE-GKAFT    SUllGEKY 


The  skin  wound  is  closed  by  a  continuous  catgut  suture 
without  drainage. 

The  outer  border  of  the  foot  is  tlius  hekl  firmly  elevated  in 
an  over-corrected  jiosition. 

The  saline  compress  is  removed  from  the  wound  on  the 
inner  border  of  the  foot,  and  while  the  foot  is  held  l:)y  an  assist- 
ant in  a  well-abducted  position,  an  accurate  measure  is  ob- 
tained of  the  resulting  cavity  between  the  head  of  the  astragalus 
and  the  scaphoid.     A  saline  compress  is  again  placed  in  this 


Fig.   247. — -4  indicates  tibial  graft  mortised  into  head  of  astragalus  and  scaphoid 

6  months  before. 


wound,  and  a  graft  corresponding  to  the  measurements  obtained 
is  removed  from  the  central  portion  of  the  tibia  where  the  cortex 
is  of  sufficient  thickness.  As  in  the  case  of  the  graft  obtained 
for  the  correction  of  congenital  clubfoot.  It  is  drilled  for 
fixation  sutures  before  it  is  dislodged  from  the  tibia.  If  the  bone 
of  the  head  of  the  astragalus  and  scaphoid  is  too  dense  to  permit 
the  passage  of  a  strong  curved  needle,  the  necessary  holes  are 
drilled  with  the  motor  drill.  Ordinarily  in  children,  the  soft- 
ness of  the  bones  permits  puncture  by  the  strong  cervix  needle, 
and  the  technique  is  carried  out  as  follows  in  either  case: 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


327 


The  kangaroo  tendon  is  threaded  through  the  drill  holes  of 
the  graft  wedge,  by  virtue  of  its  own  stiffness.  A  cervix  needle 
is  then  threaded  to  each  end  of  this  tendon.  These  needles 
are  thrust  through  the  head  of  the  astragalus  and  the  scaphoid 
at  their  inner  borders  from  their  cut  surfaces. 

The  bone-graft  wedge  is  then  forced  into  place  and  the 
tendon  suture  is  drawn  taut  and  tied  over  the  graft. 

Soule's  modification  of  author's  technique  which  is  simple 
in    that    it    does    not    require    drilling    of    bone    or    fixation 


Fig.  248. — Demonstrates  exposure  of  astragalo-scaphoid  joint  for  insertion   mortise 
graft  for  paralytic  clubfoot  (foot  represented  as  on  operating  table). 

suture,  is  recommended  whenever  it  is  found  feasible.  The 
astragalo-scaphoid  joint  is  approached  from  its  superior  as- 
pect and  all  the  articular  cartilage  is  removed  from  both 
bones,  preserving  the  original  contour  of  the  joint.  A  mortise 
is  formed  in  the  inner  portion  of  the  cut  surface  of  each 
bone,  as  shown  by  the  diagrams.  The  graft  is  so  shaped  in  its 
removal  from  the  tibia  that  it  fits  accurately  into  these  mortises 
when  the  foot  is  over-corrected.  These  mortises  lock  the  graft 
in  position  and  the  foot  is  wedged  securely  into  full  correction. 


328 


BON K-(i HAFT    SURGERY 


Fig.  249. — Dotted  lines  indicate  removal  of  cartilage  in  arthrodesing  the  astragalo- 
scaphoid  joint  or  as  a  preliminary  measure  before  mortising  in  graft  for  paralytic  club- 
foot (talipes  equino  vai'us). 


Fig.  250. ^To  illustrate  method  of  mortising  tibial  graft  for  paralytic  talipes  equino 

varus  (clubfoot). 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


329 


V     V     V 


Fig.  251. — Carvers  gouge,  with  three  different  cutting  edges.     These  tools  are  used 
bj-  the  author  in  various  osteoplastic  operations  and  are  verj'  useful. 


Fig.  252. — Method  of  removal  and  tj-pe  of  graft  used  to  mortise  into  the  head  of  the 
astragalus  and  the  scaphoid  in  the  correction  of  paralytic  clubfoot. 


330 


BONE-GRAFT   SURGERY 


By  this  niethod,  the  foot  is  insured  against  relapse,  and  at  the 
same  time  the  abnormal  laxity  of  the  medio-tarsal  joint  is  per- 
manently overcome  by  the  ankylosis  of  this  joint.  Weight 
bearing  is  placed  further  toward  tli(»  Iiiikt  ])order  of  the  foot, 
and  the  anterior  tibial  muscle,  wliicli  was  barely  able  to  func- 


FiG.   253. — Paralytic  clubfoot  (talipes  equino  varus)  with  mortise  graft  in  place.      No 
fixation  suture  is  necessary. 


tionate  before  the  operation,  is  now  made  to  do  more  than  its 
normal  amount  of  work.  A  stable  foot  is  furnished,  capable  of 
weight  bearing,  usually  without  the  additional  support  from  a 
brace. 

Arthrodesis  of  Astragalo -scaphoid  Joint  for  Flat-foot. — ^Per- 
sistently    relapsing,    painful,    and    relaxed    pronated    flat-foot 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


331 


after  thorough  treatment  by  conservative  means  has  failed, 
can  be  restored  by  arthrodesing  the  astragalo-scaphoid 
joint,  and  where  the  scaphoid  presents  prominently  the  fixation 
and  corrected  position  of  the  foot  is  fortified  by  drilling  through 
this  prominent  scaphoid  into  the  head  of  the  astragalus,  as 
advocated  bv  Soule, 


Fig.  254. — Paralytic  flat-foot  from  paralysis  of  the  anterior  tibial  muscle.  This  type 
of  deformity  can  be  best  corrected  and  controlled  by  an  arthrodesis  of  the  astragalo- 
scaphoid  joint  with  or  without  a  bone-graft  peg  and  a  transplantation  of  the  peronei 
into  the  anterior  tibial  tendon  and  scaphoid  bone. 

The  foot  and  leg  having  been  prepared,  and  a  tourniquet 
tightly  apphed  above  the  knee,  the  foot,  if  rigid,  is  thoroughly 
loosened  up,  after  the  manner  of  correcting  rigid  flat-foot — 
first,  by  forcing  the  foot  into  equinus,  and  then  by  strongly 
adducting  and  dorso-flexing  the  forefoot.  This  causes  the 
scaphoid  to  rotate  about  the  head  of  the  astragalus  into  a  more 
normal    position.     The    foot    is    thoroughly    loosened    up    by 


332 


BONE-GKAFT    .Sl'IKJEKY 


wrenching.  The  arthrodesis  of  the  astrasalo-scaphoid  joint 
is  done  with  a  curved  gouge  through  a  skin  incision,  about  2 
in.  long,  beginning  just  in  front  of  the  internal  malleolus  and 
extending  along  the  course  of  the  anterior  tibial  tendon,  which 
is  then  retracted  and  the  joint  exposed  along  its  dorsal  aspect  by 
freeing  the  overlying  joint  ligaments  and  making  strong  flexion 
of  the  foot.  The  joint  surfaces  are  thoroughly  freed  of  articular 
cartilage,  but  care  is  taken  to  preserve  the  ovoid  shape  of  the 
head  of  the  astragalus  and  the  convexity  of  the  scaphoid,  so  that 


Fig.  255. — Drawing  of  a  case  of  paralytic  talipes  valgus  before  and  after  arthrodesis 
of  the  astragalo-scaphoid  joint  and  transplantation  of  peroneus  longus  and  brevis  into 
the  scaphoid  bone  to  functionate  for  the  lost  anterior  tibial  muscle. 

when  the  forefoot  is  adducted  to  its  proper  corrected  position  the 
convexity  of  the  scaphoid  rotates  about  and  remains  in  contact 
with  the  denuded  head  of  the  astragalus. 

With  the  foot  held  in  its  corrected  position  by  an  assistant,  a 
hole  is  drilled  through  the  prominent  inner  portion  of  the  scaphoid 
obUquely  into  the  head  of  the  astragalus,  large  enough  to  admit 
a  sufficiently  strong  autogenous  bone  dowel.  The  drill  is  left  in 
position  while  the  bone  graft  is  being  removed  from  the  crest  of 
the  tibia  at  about  its  middle  third  where  the  cortex  is  thick, 
either  with  mallet  and  chisel  or,  preferably,  by  the  motor  saw. 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  333 

This  bone  is  next  passed  through  the  author's  motor  dowel 
shaper,  forming  a  bone  nail  to  fit  the  drilled  hole  in  the  scaphoid. 
This  bone  nail  can  be  shaped  with  cutting  forceps  and  a  rasp  or 
file,  if  the  dowel-shaper  and  motor  outfit  is  not  available. 

The  foot  being  held  securely  by  the  assistant,  the  drill  is 
withdrawn  and  the  bone  dowel  is  driven  into  its  place.  The 
superfluous  end  of  the  dowel  protruding  from  the  scaphoid  is  cut 
off  with  the  small  motor  saw,  and  the  skin  is  closed  over  with 
plain  catgut  sutures,  without  drainage.  The  foot  is  put  up  in  a 
plaster-of-Paris  case  extending  above  the  flexed  knee.  This  case 
remains  on  for  the  same  length  of  time  as  advocated  for  the  bone- 
wedge  cases  of  clubfoot,  and  is  removed  in  the  same  sequence, 
namely,  that  portion  enclosing  the  knee  is  removed  after  6  weeks, 
followed  4  weeks  later  by  the  removal  of  the  remainder. 

As  in  the  case  of  other  bone-grafting  procedures,  it  is  well  in 
some  instances  to  protect  the  part  from  undue  strain  by  having 
the  patient  wear  a  metal  flat-foot  plate  for  a  few  months,  until 
the  proliferation  changes  and  adjustment  of  the  grafted  parts 
are  complete.  This  plate  should  be  accurately  made  over  a 
plaster-of-Paris  model  of  the  corrected  foot,  as  in  the  case  of  all 
flat-foot  plates,  the  Whitman  plate  being  preferred. 

ARTHRODESIS  OF  ANKLE 

In  cases  of  marked  laxity  of  the  foot  on  the  leg.  Lexer  has 
applied  the  autogenous  bone-graft  dowel  by  passing  it  through 
the  anterior  end  of  the  os  calcis  and  body  of  the  astragalus  into 
the  low^er  end  of  the  tibia.  According  to  Lexer:  '^This  canal 
should  not  be  made  too  wide,  as  the  bolt  must  be  inserted  for- 
cibly so  that  blood  and  detached  marrow  cannot  collect  between 
it  and  the  bone,  since  bone  will  unite  with  the  surrounding  bony 
tissue  only  when  it  lies  in  intimate  contact  with  it,  otherwise 
granulations  appear  in  the  walls  of  the  canal,  interfere  with  nu- 
trition and  predispose  to  rapid  absorption.  Some  of  the  failures 
reported  are  due  to  this  technical  error.  It  is  a  strange  fact 
that  this  bolt  stimulates  thickening  of  the  spongy  portion  of 


334 


BONE-GRAFT   SURGERY 


the  bone,  while  it  is  absorbed  in  the  upper  ankle.  There- 
fore ossification  rarely  takes  place  in  this  joint,  as  a  rule,  only 
the  necessary  immobilization.  This  procedure  is  simpler  than 
the  usual  arthroplasty,  and  with  proper  care  yields  satis- 
factory and  permanent  results"  (Lexer).  The  author,  how- 
ever, believes  that  this  is  not  an  operation  to  be  depended 
upon,  as  the  articular  cartilages  are  not  disturbed  and  cellular 


Fig.  256. — Illustrating  Soule's  technique  for  severe  flat-foot  and  the  pronated  foot 
resulting  from  infantile  paralysis.  The  cartilage  from  head  of  astragalus  and  posterior 
surface  of  the  scaphoid  bone  is  removed  at  arrow  point.  A  tibial  graft  peg  is  then 
inserted  as  indicated. 


osteoclasis  is  likely  to  interfere  with  the  integrity  of  the  trans- 
plant. This  opinion  is  supported  by  Schew^andin  who  reports 
in  ArcMv.  f.  klin.  Chir.,  vol.  ci,  p.  1009,  a  few  failures  due  to  the 
giving  way  of  the  graft  at  the  joint  surfaces.  It  is  believed  that 
had  the  articular  cartilages  been  removed  from  the  ankle-joint 
at  the  time  the  transplant  was  inserted  the  results  would  have 
been  permanent. 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


335 


ASTRAGALUS  USED  AS  TRANSPLANT  TO  ARTHRODESE  ANKLE 

Wrede's  arthrodesis  of  the  ankle-joint  promises  to  be  a  trust- 
worthy operation,  since  it  establishes  a  somewhat  elastic  joint 
instead  of  a  complete  ankylosis.     At  the  same  time  the  ankle- 


> 

/       . 

';         >-;'-i;2^ 

Fig.  257. — A  case  of  anterior  polionn-elitis  witli  complete  paralysis  of  all  the  muscles 
controlling  the  right  knee.  An  arthrodesis  operation  for  stiffening  the  right  knee  was 
done  in  Warsaw,  3  years  before.  The  knee  was  fixed  with  two  strands  of  silver  wire, 
both  of  which  broke  (see  Fig.  218)  allowing  the  limb  to  become  ankylosed  at  nearly  a 
right  angle.  A  cuneiform  osteotomy  was  done  by  the  author  and  the  patella  used  as  an 
inlay.  Bony  union  occurred  immediatelj-.  (See  Fig.  219.)  To  produce  a  stable  foot, 
right  astragalus  was  removed  and  all  its  articular  cartUage  was  peeled  off,  as  well  as  the 
cartilage  on  the  contiguous  surfaces  of  the  os  calcis,  scaphoid,  tibia  and  fibula.  The  as- 
tragalus was  then  replaced  in  its  normal  position  and  the  skin  wound  was  closed.  The 
foot  was  thereby  changed  from  a  flaccid  to  a  stable  weight-laearing  foot. 


joint  does  not  become  flail-like.  It  is  indicated  in  cases  where 
the  transplantation  of  tendons  is  either  contra-indicated  or  has 
not  given  satisfactory  results.  The  ankle-joint  having  been 
exposed  by  a  Kocher  incision,  the  astragalus  is  removed  without 
being  fractured.     The  cartilaginous  surfaces  of  the  astragalus  as 


336 


BONE-GRAFT    SURGERY 


well  as  those  surfaces  articulating;  with  the  astragalus  are  re- 
moved.    The  author  uses  the  electric  rotary  saw  and  burrs  to  do 


Fig.   258. — The  heavy  line  indicates  incision  for  removal  of  the  astragalus 


Fig.   259. — E.xposure  of  astragalus  for  removal. 

this  with.     The  astragalus  denuded  of  its  periosteum  is  then 
replaced  into  its  normal  site.     The  wound  is  closed  and  a  plaster- 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  337 


of-Paris  dressing  applied  for  12  weeks.     The  astragalus  is  thus 
used  as  an  autogenous  free  graft.     Bone  ankylosis  is  not  the 


Fig.   260. — Removing  cartilage  from  the  astragalus  before  placing  it  back  in 
the  foot  as  a  graft. 


Fig.  261. — Removing  cartilage  from  surface  of  scaphoid,  os  calcis,  tibia  and  fibula 
which  articulate  with  the  astragalus. 

usual  result  unless  the  cartilage  is  removed  too  deeply.     Fibrous 
union  is  the  usual  result. 


338 


BONE-GRAFT    SURGERY 


FIXATION  OF  TUBERCULOUS  OSTITIS  OF  THE  ANKLE  BY  BONE  GRAFT 

For  the  treatment  of  tubercular  ankle-joint  and  tarsal  disease, 
the  author  has  applied  the  bone  graft  as  an  internal  fixation 
splint,   supporting  and  immobilizing  the  diseased  parts   to   a 


4?^- 


^- 


Fig.  262. — Complete  paralysis  of  all  the  muscles  controlling  the  foot  from  infantile 
paralysis.  The  astragalus  was  removed  and  all  its  articular  cartilage  peeled  off  with 
motor  saw.  Also  the  cartilage  from  the  bones  articulating  with  it  was  removed.  The 
denuded  astragalus  was  then  put  back  for  the  purpose  of  making  a  stable  ankle  and  foot. 
(For  anterior-posterior  view  see  Fig.  263.) 


degree  impossible  to  attain  by  external  splints,  and  thereby 
hastening  the  arrest  of  the  tuberculous  process. 

In  the  instance  of  an  adult,  when  the  question  of  amputation 
was  strongly  considered  to  relieve  the  patient  of  an  extensive 
tuberculous  infection   of   the  tarsus,   three  bone  grafts  were 


BONE    GRAFT    IX    THE    TREATMENT    OF    DISEASES 


339 


inserted,  one  from  the  internal  malleolus  to  the  os  calcis;  a 
second,  from  the  internal  malleolus  to  the  internal  cuneiform 
bone;  and  a  third,  from  the  external  malleolus  to  the  cuboid 
bone. 


-N^ 


Fig.  263. 


The  leg  and  foot  were  prepared  for  operation,  and  a  tourniquet 
tightly  applied  above  the  knee.  A  U-shaped  skin  flap  was 
turned  up,  exposing  the  internal  malleolus.  A  bed  for  the  fixa- 
tion of  joined  ends  of  the  grafts  coming  from  the  internal  cunei- 
form bone  and  the  os  calcis  was  prepared.     As  these  two  grafts 


340 


BONE-GRAFT    SURGERY 


Fig.  2G4. — Roiitgciiograni  of  an  acute  tubercular  ankle  in  a  young  man  20  years  of 
age.  The  symptoms  were  not  relieved  by  a  carefully  fitted  plaster-of-Paris  dressing 
and  month  of  recumbency  in  bed.  Pain  was  entirely  relieved  by  the  insertion  of  bone 
grafts  from  the  external  and  internal  malleoli  to  the  posterior  end  of  the  os  calcis,  the 
cuboid  bone  and  the  internal  cuneiform. 


>*:.    '^s^M 


1=-. 


Fig.  265. — Rontgenogram  taken  2  months  after  the  insertion  of  the  graft.  AF 
is  graft  from  internal  malleolus  to  internal  cuneiform.  CD  is  graft  from  external  malleo- 
lus to  the  cuboid       DE  is  graft  from  external  malleolus  to  the  os  calcis. 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


341 


were  to  be  joined  at  an  obtuse  angle,  in  the  manner  of  an 
inverted  "V,"  the  bed  was  prepared  by  turning  one  osteo- 
periosteal flap  down  and  two  upward,  with  a  sharp  osteotome. 
Short  skin  incisions  were  likewise  made  over  the  inner  surface  of 
the  posterior  portion  of  the  os  calcis  and  internal  cuneiform 
bone,  and  beds  were  prepared  for  the  ends  of  the  grafts  by  turn- 


ip 


Fig.  266. — Rontgenogram  of  same  case  as  Fig.  267  taken  2  years  and  4  months 
after  the  insertion  of  the  bone  grafts.  The  symptoms  remain  entirely  relieved  and  the 
disease  apparently  cured.  The  hypertrophy  and  increa.se  in  density  of  the  graft  are 
very  striking,  especially  at  B  and  D.  The  fibula  in  which  they  are  inserted  is 
even  hypertrophied  from  increased  stress  at  -4.. 


ing  up  osteoperiosteal  flaps.  Subcutaneous  tunnels  were  made 
with  a  broad  ligament  clamp,  joining  these  incisions  with  the 
one  over  the  internal  malleolus. 

The  same  procedure  was  carried  out  in  forming  a  bed  for  a 
graft  reaching  from  the  external  malleolus  forward  to  the  cuboid 
bone.     The  lengths  of  these  grafts  were  determined  with  calipers. 


342 


BONE-GHAFT    SURGERY 


The  antero-iiiteriRil  surface  of  the  tibia  of  tlie  same  leg  was  then 
exposed,  and  with  the  twin  motor  saw%  the  required  grafts,  each 
three-eighths  of  an  incli  wide  and  \\\v  full  thickness  of  the  cortex, 
were  removed  from  the  central  ])()rti()n  of  this  tibial  surface. 
The  ends  of  the  two  grafts  which  were  to  be  joined  at  the  internal 
malleolus  were  mortised.  This  was  very  quickly  done  with  the 
motor  saw.  These  two  grafts  were  pushed  through  the  subcuta- 
neous tunnels  already  prepared  for  them,  the  mortised  ends 
joined,  and  they  were  covered  in  by  the  osteoperiosteal  flaps 


Fig.  267. — Same  case  as  Figs.  265  and  266  showing  excellent  weight-bearing 
function  and  outline  of  graft  extending  from  internal  malleolus  to  internal  cuneiform 
bone. 

which  were  drawn  over  them  with  interrupted  sutures  of  medium 
kangaroo  tendon. 

The  other  ends  of  these  grafts,  as  well  as  the  graft  implanted 
on  the  outside  of  the  foot,  were  secured  in  place  in  a  similar 
manner.  The  skin  wounds  w^ere  closed  by  continuous  catgut 
sutures,  and  a  plaster-of-Paris  dressing  was  applied  with  the  foot 
at  a  right  angle. 

Figure  266  is  arontgenogram  of  this  patient's  foot,  taken  over 
2  years  after  operation,  showing  the  grafts  present  and  securely 
grow^n  in.  At  the  time  of  operation,  in  preparing  the  bed  for  the 
graft  of  the  external  side  of  the  foot,  tuberculous  tissue  was 
accidentally    opened    into    and,    although    the    graft    spanned 


BONE    GRAFT    IX    THE    TREATMENT    OF    DISEASES  343 

through  this  area  of  mfected  tissue,  it  healed  in  promptly. 
This  is  one  of  many  instances  where  the  author  has  placed 
grafts  through  tuberculous  areas  without  interference  with  the 
union  of  the  graft  to  its  bed.  The  result  in  this  case  was  espe- 
cially gratifying  because  the  tarsal  osteitis  was  advanced  and 
very  acute  at  the  time  of  operation,  and  a  well-moulded  plaster 
cast  with  recumbency  in  bed  had  failed  to  reUeve  the  pain. 
With  the  implantation  of  the  bone  grafts,  pain  immediately 
subsided  and  the  disease  was  completely  arrested.  One  year 
later  walking  and  weight-bearing  produced  no  pain  or  other 
evidence  of  active  disease,  and  this  relief  of  sjanptoms  has  per- 
sisted to  the  present  time,  over  2  years  after  the  operation,  in 
spite  of  the  fact  that  during  the  past  6  months  the  patient  has 
developed  a  tuberculous  infection  of  the  kidney  and  a  relapse  of 
the  lung  condition  from  which  he  suffered  prior  to  the  operation. 

BONE  GRAFT  TO  RESTORE  BONES  DESTROYED  BY  TUBERCULOSIS 

In  case  the  tuberculous  process  is  limited  to  an  individual 
tarsal  bone  or  group  of  bones,  shorter  grafts  can  be  used  to  fix 
these  localized  diseased  areas  with  equal  success.  In  this  event, 
the  graft  is  implanted  into  the  healthy  bones  on  each  side  of  the 
focus  of  disease,  and  spans  it.  The  diseased  tissues  may  or  may 
not  be  removed,  according  to  judgment. 

In  the  case  of  a  single  tuberculous  bone  of  the  tarsus  being 
involved,  this  bone  can  in  selected  cases  be  removed  and  a  bone 
graft  modelled  to  take  its  place  and  fill  in  the  deficiency,  thus 
preventing  malformation  of  the  foot  resulting  from  loss  of  sup- 
port by  the  removal  of  the  infected  bone. 

THE  BONE   GRAFT  IN   THE  TREATMENT    OF    CONGENITAL   ABSENCE 

OF   FIBULA 

Author's  Technique. — ^The  congenital  absence  of  one  or  both 
bones  of  the  leg  is  a  deformity  which  owes  a  great  deal  of  its 
interest  to  its  rarity. 

The  absence  of  this  bone  is  practically  always  associated  wuth 
other  malformations  in  the  leg,  such  as  talipes  valgus,  syndac- 


3-44 


BONE-GRAFT    SUKGERY 


tylism,  the  sup]:)ression  of  one  or  more  toes,  deformity  of  the 
femur,  malformations  of  the  tarsus  or  knee. 

According  to  Corner,  200  cases  of  absence  of  the  fibula  have 
been  collected.  He  also  states  that  all  operative  treatment  of 
congenital  absence  of  the  fibula  is  generally  unsatisfactory, 
and  "amputation  in  consequence  is  only  too  often  necessary." 


,-sinqle:sav/ 


TWIN  SAW 


Fig.  268.  Fig.  269. 

Fig.  268. — Absent  lower  end  of  fibula.  Indicates  method  of  splitting  lower  end  of 
upper  fragment  of  a  fibula  and  of  obtaining  the  graft  from  the  tibia.  That  portion  of 
the  graft  marked  as  cut  with  single  saw  is  wedge  shaped.      (See  Fig.  269.) 

Fig.  269. — Graft  used  for  absence  (congenitally  or  otherwise)  of  lower  end  of  fibula, 
joined  to  the  upper  end  of  fibula  by  the  tongue  and  groove  joint  and  ligatures  of  kan- 
garoo tendon.      The  cavity  in  a  tibia  indicates  the  source  of  the  graft  material. 

Wille  in  1909  did  an  arthrodesis  by  driving  a  portion  of  a 
fibula  (obtained  from  an  amputated  leg)  up  from  the  sole  of  the 
foot  through  the  os  calcis,  astragalus  and  tibia,  and  obtained  a 
fair  result  but  without  motion. 

Where  there  is   found   to   be  a   congenital'  deficiency,   the 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


345 


implantation  of  bone  shaped  and  adapted  to  correct  the  resulting 
deformity  can  be  resorted  to.  The  following  case  illustrates  the 
treatment  of  such  a  condition: 

A  child  was  born  with  the  foot  and  lower  third  of  the  left 


t^ 


-r^jg^- 


FiG.  270. — Rontgenogranis  of  case  of  partial  congenital  absence  or  interuterine 
fracture  of  the  lower  end  of  the  fibula  with  a  marked  valgus  deformity  on  account  of  the 
absent  support  of  the  external  malleolus.  It  will  be  noted  that  the  lower  end  of  fibula,  B, 
has  become  displaced  and  is  posterior  to  body  of  the  astragalus  rather  than  lateral  to  it. 
This  fragment  was  removed.  The  deformity  corrected  by  severing  soft  structures  and 
forcible  stretching.  The  lower  end  of  the  fibula  with  its  support  was  then  supplied  by  a 
graft  from  the  opposite  tibia. 

leg  absent.  A  conical  stump  containing  an  undeveloped  tibia 
projected  backward  from  the  posterior  aspect  of  the  thigh.  The 
right  fibula  was  entirely  absent,  and  on  this  account  the  foot  on 
this  hmb  had  become  displaced  from  weight-bearing  and  muscle- 


346 


BONE-GRAFT    SURGERY 


pull  to  a  iiroiuitcd  i)osition,  with  its  plantar  surface  facinj^  directly 
outward  and  firmly  contractured.  The  lower  end  of  the  internal 
malleolus  had  become  the  chief  weight-bearing  portion  of  the 
foot. 


Fig.  271.  Fig.  272. 

Figs.  271  and  272. — Partial  congenital  ab.sence  of  the  lower  end  of  the  fibula  with  a 
consequent  marked  valgus  deformity  of  the  foot  from  lack  of  support  of  the  external 
malleolus.     AB  is  a  tibial  graft  to  restore  fibula  after  correction  of  deformity. 


The  problem  which  presented  in  this  case  (a  child  5  years  of 
age)  was,  if  possible,  to  correct  the  distorted  foot  and  provide  a 
means  of  maintaining  the  correction  without  at  the  same  time 
interfering  seriously  with  its  function  by  the  loss  of  ankle  motion. 
The  most  feasible  method  in  these  cases  is  to  supply  the  missing 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  347 

support  of  the  lower  end  of  the  fibula.  This  is  best  done  by 
restoring  the  bony  anatomy  of  the  part,  which  can  be  accom- 
plished in  no  other  way  than  by  resorting  to  the  use  of  the  bone 
graft. 

In  this  instance,  excellent  material  for  this  purpose  was  easily 
obtained  from  the  conical  stump  of  the  left  leg.  (Figs.  274-276.) 
The  technique  of  the  procedure  was  as  follows :  A  curved  incision, 
so  placed  that  its  closure  w^ould  not  bring  the  skin  sutures  over 
the  contemplated  site  of  the  graft,  w^as  made  over  the  outer  and 


Fig.  273. — Rontgenogram  of  same  ca.se  as  Figs.  270  to  272.  A  is  tibial  graft  6 
months  after  insertion  for  absent  lower  end  of  fibula.  It  supplies  very  firm  support 
and  allows  very  free  ankle  motion.  The  upper  end  of  graft  was  made  with  a  wedge 
end  and  was  inserted  into  the  split  end  of  the  upper  fragment  of  the  fibula. 

lower  end  of  the  tibia  and  the  outer  surface  of  the  os  calcis.  The 
position  of  the  foot  was  corrected  after  extensive  division  of 
fascia,  ligaments,  and  contracted  tissue.  The  outer  aspect  of 
the  lower  end  of  the  tibia  was  exposed,  and  the  periosteum  was 
split  longitudinally  from  a  point  about  i^  in.  above  the  epi- 
physeal line  extending  upward  for  about  II2  in.  These  perios- 
teal flaps  w^ere  retracted  laterally  and,  with  the  twin  saw  ad- 
justed about  I4  to  3^  in.  apart,  cuts  were  made  in  the  long  axis  of 
this  bone  from  1 2  ^^^-  above  the  epiphyseal  cartilage  upward  for 
about  1  in.     The  strip  of  bone  between  these  saw-cuts  was  then 


348 


BONE-GRAFT    SURGERY 


removed  with  tho  help  of  the  author's  small  circular  motor  saw 
and  a  sharji  narrow  osteotome.  Caliper  measurements  were 
taken  and  the  size  and  shai)e  of  the  desired  graft  platmed.  The 
lower  end  of  the  tibia  near  its  outer  jXJi'tion  was  drilled  for  a 


Fig.  274. — Congenital  absence  of  the  right  leg.  The  conical  stump  contains  an 
under-developed  tibia,  shown  in  Fig.  276  A,  as  well  as  small  under-developed  foot  bones. 
It  was  necessary  in  any  event  to  remove  this  conical  projection  in  order  to  furnish  a 
suitable  stump  for  an  artificial  limb. 

The  fibula  is  entirely  absent  from  the  left  leg  and  the  foot  and  on  account  of  lack  of 
support  of  the  external  malleous  the  foot  is  so  distorted  that  the  internal  malleous 
rests  on  the  floor.  The  deformity  of  the  foot  was  corrected  by  lengthening  the  tendons 
and  severing  the  soft  tissues  on  the  outer  side  of  the  ankle,  and  the  under-developed 
tibia  of  the  amputated  stump  of  the  right  leg  served  as. an  ideal  graft  according  to  the 
technique  illustrated  in  Fig.  277.  This  case  was  kindly  referred  by  Dr.  C.  B.  Lufburrow, 
Plainfield,  N.  J. 

kangaroo  fixation  suture,  antero-posteriorly  about  I4  in.  above 
its  epiphyseal  cartilage. 

The  wound  was  packed  with  a  hot  saline  compress,  and  the 
conical  stump  of  the  left  leg  containing  the  undeveloped  tibia  was 


BONE    GRAFT    IX    THE    TREATMENT    OF    DISEASES 


349 


fi 


Fig. 


275. — Anterior-posterior  rontgenogram  of  same  case  as  Fig.  274.       The  absence 
of  the  fibula  and  the  displacement  of  the  os  calcis,  .4,  and  astragalus  is  shown. 


350 


BONE-GRAFT   SURGERY 


removed  through  an  elhptical  incision,  so  planned  that  a  satis- 
factory artificial  limb-bearing  stump  would  be  produced.  This 
wound  in  the  left  leg  was  closed  by  a  continuous  catgut  suture 
and  sterile  dressings  were  applied.  The  conical  stump  of  this  left 
leg  which  had  been  removed  was  then  freed  of  its  undeveloped 
tibial  segment,  which  was  moulded  with  motor  tools  to  simulate 
the  contour  of  the  lower  end  of  the  fibula.     With  the  twin  motor 


Fig.  276.— Is  a  rontgenogi'am  of  stump  of  same  case  as  Fig.  274.  It  shows  the 
under-developed  tibia  which  was  used  as  a  graft  to  restore  the  external  malleolus  of  the 
child's  left  leg. 

saw  adjusted  for  making  the  gutter  in  the  tibia,  cuts  were  made 
into  the  upper  end  of  this  graft  for  the  purpose  of  framing  a 
tongue  which  would  mortise  into  the  groove  already  prepared 
in  the  tibia,  as  shown  by  drawings  (Fig.  277),  which  prevented 
the  graft  from  riding  up  on  the  tibia.  The  upper  end  of  this 
mortised  tongue  was  shaped  into  an  extended  hook  for  the 
purpose  of  hooking  under  and  internally  (medullary  side)  to  the 
cortex  of  the  upper  end  of  the  tibial  groove.     When  the  graft  was 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  351 


352 


BONE-GRAFT   SURGERY 


B 


Fig.  278. — Is  a  rontgenogram  of  the  same  case  as  Fig.  274.  Shows  the  correction  of 
the  marked  valgus  deformity  and  the  bone  graft,  AB,  united  in  position  4  months  after 
its  transplantation. 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES  353 

in  position,  this  mortised  joint  fitted  accurately  because  both 
groove  in  tibia  and  mortised  tongue  of  graft  were  fashioned  with 
the  twin  saws  at  the  same  distance  apart. 

The  graft  was  further  secured  in  its  position  by  passing  the 
heavy  kangaroo  tendon  through  drill  holes  in  the  lower  end  of 
the  tibia  and  tying  it  securely  about  the  graft  (Fig.  277). 
The  freshened  surfaces  of  the  graft  on  either  side  and  below  the 


Fig.  279. — Photograph  of  the  sumu  cusc  as  Fig.  274,  4  months  after  operation. 
Shows  correction  of  the  distortion  of  the  left  foot,  also  the  well-formed  stump  of  the  right 
leg.  The  arrow  indicates  a  Wolff's  skin  graft  (about  2ii  in.  by  l]i  in.),  which  had  been 
obtained  from  the  trimming  of  the  stump  of  the  right  leg. 

It  was  found  after  the  correction  of  the  valgus  deformity  of  the  foot  and  the  insertion 
of  the  bone  graft  that  there  was  not  enough  skin  to  close  in  the  external  side  of  the  leg, 
and  a  skin  graft  was  used  to  fill  in  the  uncovered  area.  Both  skin  and  bone  grafts  healed 
in  bj-  primary  union. 

mortised  joint  were  held  in  close  apposition  to  the  periosteal- 
denuded  surface  of  the  lower  end  of  the  tibia.  An  attempt  to 
close  the  skin  over  the  graft  disclosed  the  fact  that  the  correc- 
tion of  this  extreme  deformity  had  so  elongated  the  outer  side 
of  the  leg  and  foot  that  the  contracted  skin  was  not  sufficient 
to  cover  it,  and  therefore  the  skin  wound  could  not  be  closed. 
To  meet  this  difficulty  we  again  returned  to  the  trimmings  of 
the  left  leg,  and  dissected  therefrom  an  oval  segment  of  skin 


354  BONE-GRAFT    SURGERY 

(a  Wolff  graft)  about  2'  i  in.  long  by  about  I'-j  in.  wide.  This 
was  sufficient  to  complete  the  skin  closure,  and  was  so  placed 
as  not  to  overlie  the  bone  graft  or  bring  the  skin  sutures  over 
the  graft.  Sterile  dressings  were  applied  and  a  plaster-of-Paris 
dressing  was  put  over  all. 

The  convalescence  was  uninterrupted.  All  the  wounds 
healed  by  primary  union,  and  both  skin  graft  and  bone  graft 
healed  in  kindly.  The  result,  after  6  months,  is  most  gratify- 
ing, the  foot  being  corrected  and  held  in  excellent  position  by 
this  improvised  malleolus. 


Fig.  280. — A  result  aftei-  the  correction  of  congenital  deformities  of  both  feet  and  the 
insertion  of  bone  grafts  obtained  from  two  cadavera.  The  deformities  in  this  case  were 
very  unusual  and  due  to  the  absence  of  the  internal  cuneiform  and  partial  absence  of  the 
scaphoid  bones.  The  forefeet  were  consequently  markedly  adducted  because  of  the  lack 
of  bony  support.      (For  rontgenogram,  see  Fig.  281.) 

Another  case  of  a  similar  nature,  but  with  only  a  portion  of  the 
lower  half  of  the  fibula  absent,  was  corrected  by  taking  a  suffi- 
ciently long  graft  from  the  tibia  and  bevelling  one  end  on  both 
sides  into  the  shape  of  a  wedge,  so  as  to  slip  it  in  between  the  two 
halves  of  the  split  lower  end  of  the  remaining  portion  of  the 
fibula.  The  lower  end  of  the  graft  was  made  to  take  the  place 
of  the  absent  external  malleolus  and  prop  the  foot  into  a  cor- 
rected position  (Figs.  268-273). 

RESTORATION  OF  BONES  OF  FOOT 

Another  instance  of  the  use  of  the  bone  graft  is  that  of  the 
disintegration  of  an  individual  tarsal  bone  of  the  foot,  such  as  is 


BONE    GRAFT    IN    THE    TREATMENT    OF    DISEASES 


355 


occasionally  found  in  the  destruction  and  breaking  down  of  the 
scaphoid,  causing  the  foot  to  sharply  contract  at  this  point, 
forming  by  the  resultant  cicatrix  a  sharply  inverted  forefoot. 
In  such  a  case,  to  overcome  the  deformity,  the  remnants  of  the 


Fig.  281. — AB  is  a  graft  consisting  of  about  one-third  of  a  humerus  obtained  from 
the  body  of  an  infant  strangulated  at  birth,  and  used  as  a  prop  support  to  the  inner  side 
of  the  foot.  One  end  is  inserted  into  a  notch  made  in  the  side  of  the  first  metacarpal 
bone  and  the  other  end  into  a  cup-shaped  cavity  made  in  the  anterior  surface  of  the 
under-developed  scaphoid.  CD  is  a  portion  of  a  femur  obtained  from  the  body  of 
another  infant  strangulated  at  birth,  and  inserted  by  the  same  technique.  Both  bone 
grafts  were  immersed  in  sterile  vaseline  and  left  48  hours  in  a  cold  storage  plant  at  4  to 
5°  C.  This  case  has  been  under  observation  3  years  since  the  insertion  of  the  graft.  The 
result  is  excellent. 


broken-down  or  infected  bone  are  removed,  and  the  head  of  the 
astragalus  and  internal  cuneiform  bone  are  exposed  through  the 
usual  curved  skin  incision,  and  either  by  the  inlay  method  or  by 
boring  one  of  these  bones  and  slotting  the  other,  a  graft  pre- 
viously removed  from  the  crest  of  the  tibia  is  inserted.     The 


356  BONE-GRAFT    SURGERY 

shai:)0  of  such  a  <i;i'afl  is  foi'iiuMl  by  llic  iiiotoi-  saw,  and  is  illus- 
trated in  a  general  way  by  the  acc()nii)anyin«;(liagrams  (Figs. 
296  and  297). 

The  implant  fits  into  gutters  made  in  the  superior  aspects  of 
the  hones  which  are  to  hold  th(>  graft.  Fixation  sutures  may 
or  may  not  he  necessary.  The  centrally  placed  end  (jf  the 
implant  is  held  by  the  natural  tension  of  the  tissues,  tending  to 
draw  the  separated  bones  togethei-,  and  the  dowel  ends  fit  into  a 
drill  hole  at  one  end  while  the  inlaid  other  end  is  held  by  a  bone 
suture,  if  it  is  found  necessary.  The  thicker  central  portion 
of  the  gi'aft  gi\'es  sti'ength  and  fui'nishes  shoulders  to  the  inlay 
or  dowel,  which  prevents  further  approximation  of  the  astragalus 
and  cuneiform  bones. 

Tliis  same  technique  is  api)licable  also  in  the  case  of  the 
destruction  or  partial  disintegration  of  any  bone  b}'  tuberculosis 
or  attenuated  pyogenic  infection,  such  as  a  tarsal  or  carpal 
bone  or  a  phalanx  in  spina  ventosa,  etc. 


CHAPTER  VIII 

MISCELLANEOUS    SURGICAL    USES    OF    THE    BONE    GRAFT 

In  this  chapter  an  attempt  will  be  made  to  cover  the  tech- 
nique of  a  considerable  number  of  additional  surgical  uses  for  the 
bone  graft.     Conditions  which  make  it  necessary  to  replace  bony 


Fig.   282. — Absence  of  central  portion  of  tibia  from  old  osteomyelitis. 

defects  are  by  no  means  of  rare  occurrence.  The  most  frequent 
and  important  of  these  are  deficiencies  of  the  cranial  bones,  of 
the  inferior  maxilla,  and  of  the  long  bones  of  the  extremities, 

357 


358 


BONE-GRAFT    SUHGERY 


Fig.  283. — Same  case  as  Fig.  282,  one  year  after  insertion  of  graft.  The  upper  tibial 
fragment  was  split  with  motor  saw  and  the  upper  end  of  the  graft,  being  made  with 
wedge  end,  was  inserted  into  saw-cut  cleft  at  A.  The  lower  end  was  inlaid  by  author's 
usual  technique  at  B. 


SURGICAL    USES    OF    THE    BONE    GRAFT  359 

caused  by  removal  of  tumors,  by  osteomyelitis,  and  by  injuries. 
Many  modifications  of  the  pedunculated  method  of  restoring 
bony  defects  have  been  described  by  Bittner,  Oilier,  Miiller, 
Vulpius,  Codi villa,  and  Huntington.  These  methods  were 
devised  and  practised  largely  before  the  trustworthiness  of  the 
free  autogenous  bone  graft  had  become  established.  On 
account  of  the  added  complexity  of  operative  technique  and 
the  small  chances  of  blood  supply  reaching  the  graft  through  its 
twisted  pedicle,  the  disadvantages  of  this  technique  far  out- 
weigh its  advantages. 

For  absence  of  the  tibia  from  destruction  by  osteomyelitis  or 
new  growths,  or  failure  of  regeneration,  or  from  congenital  ab- 
sence, etc.,  the  upper  part  of  the  fibula  may  be  moved  over  to  a 
socket  cut  in  the  upper  epiphysis  of  the  tibia.  As  reported  by 
Hahn  (1884),  Nichols  (1904),  Huntington  (1905)  and  others,  the 
fibula  underwent  hypertrophy  and  supported  the  weight  of  the 
body  very  well.  Huntington,  in  the  Annals  of  Surgery,  1905, 
vol.  xli,  p.  249,  first  described  his  operation  for  substituting  for 
the  whole  diaphysis  of  the  tibia  that  of  the  fibula  of  the  same 
leg.  The  fibula  is  divided  with  a  saw  at  a  point  opposite  the 
lower  end  of  the  upper  tibial  fragment,  the  distal  portion  of  the 
fibula  is  firmly  planted  in  a  cup-shaped  depression  in  the  upper 
fragment  of  the  tibia.  In  Huntington's  first  case  the  union  was 
very  slow  and  solidification  did  not  finally  occur  until  6  months 
later.  In  this  case  he  did  not  transfer  the  lower  end  of  the  fibula 
to  the  lower  fragment  of  the  tibia  until  8  months  later.  The 
consequent  faulty  weight  bearing  over  this  long  period  of  time 
caused  a  permanent  change  in  the  conformation  of  the  tarsus  and 
an  outward  alignment  of  the  axis  of  the  lower  end  of  the  tibia. 

Stone  {Annals  of  Surgery,  xlvi,  p.  628)  transfers  the  upper 
end  of  the  fibula  into  the  tibia  by  precisely  the  same  technique 
as  Huntington.  The  lower  end  of  the  diaphysis,  however,  he 
splits  longitudinally  with  a  chisel  for  a  distance  of  4  in.,  care 
being  taken  to  avoid  separating  the  periosteum  from  either 
half  of  the  bone.  At  the  lower  end  of  the  split  portion,  the 
inner  half  is  cut  transversely  at  the  level  of  the  upper  part 


360 


BONE-GRAFT   SURGERY 


of  the  roiiuiiiiiii^-  \n\\cv  (epiphysis  of  tlic  tihiu.  A  snuill  i)ocket 
is  tluMi  cut  in  the  (^i)iphyscal  cartilage  coveriii<2;  tli(^  oiul  of  the 
tibial  epiphysis,  just  large  enough  to  receive  the  inner  half  of  the 
fibula  fragniont  which  is  then  sprung  into  its  now  jiosition  in 
the  tibia. 

The  second  sto])  at  the  lower  end  of  the  fibula  was  ])lanned 
to  maintain  coniuH'tion  between  the  shaft  of  the  fibula  and  the 


n 


Antero-po.sTcrior  vicnv.  l.atcral  \'ic\v. 

Fig.   284. — Radiographs    taken    9    month.?    after  the    removal    of  the  .shaft  of  the 

tibia.  The  amount  of  regeneration  is  ■vvcll  shown.  (James  S.  Stone,  in  Atinals  of 
Surgery.) 

external  malleolus,  because  if  this  is  lost  the  outer  side  of  the 
ankle-joint  would  be  seriously  weakened.  At  the  same  time 
it  is  necessary  to  bring  a  portion  of  the  fibula  above  and  contact 
it  with  the  lower  epiphysis  of  the  tibia.  The  promptness  and 
the  extent  of  new  bone  formation  from  each  of  the  fibula  halves 
was  very  satisfactory  (see  Figs.  287,  288). 


SURGICAL    USES    OF    THE    BONE    GRAFT 


361 


Bond  (British  Jour.  Surgery,  April,  1914)  described  two  cases 
in  which  he  did  the  Huntington  operation  of  replacing  the  whole 
shaft  of  the  tibia  by  transplanting  the  shaft  of  the  fibula  into  its 
place.  ''The  fibula  was  cut  across  just  below  the  head  of  the 
bone,  and  this  portion  was  left  in  its  normal  position.  The 
divided  end  of  the  shaft  of  the  fibula  was  then  pushed  over  to 


Antero-posterior  view.  Lateral  view. 

Fig.  285. — Radiographs  taken  a  year  after  the  removal  of  the  shaft  of  the  tibia. 
They  show  that  no  further  regeneration  of  bone  had  occurred  since  the  preceding  X- 
rays  were  taken.  They  show,  however,  the  beginning  hypertrophy  of  the  shaft  of  the 
fibula,  most  pronounced  about  the  middle.      (.Iame.s  S.  Stone,  in  Annals  of  Surgery.) 

the  inner  side  and  inserted  into  the  freshened  lower  surface  of 
the  tibial  epiphyses,  to  Avhich  it  was  wired  in  position.  Some 
difficulty  was  experienced  in  keeping  the  sutured  bones  in  good 
position,  owing  to  the  friability  of  the  softened  bony  tissues  and 
to  the  drag  of  the  muscles,  which  tended  to  displace  the  fibula 
outward  to  its  old  position.     This  necessitated  a  second  opera- 


3G2 


BONE-GHAFT    SURGERY 


tioii  and  the  introduction  of  a,  second  silver  wire."  In  1  year 
and  10  months,  the  transference  of  the  lower  end  of  the  fibula 
was  done  at  a  third  operation.  The  fibula  was  divided  just 
above  the  external  malleolus  and  the  lower  end  of  the  shaft 
was  displaced  inward  and  inserted  into  the  soft  cancellous  tissue 
of  the  lower  tibial   extremity.     The  fibula  shaft  in  its  new 


Antero-posterior  view.  Lateral  view. 

Fig.  286. — Radiographs  taken  five  mouths  after  the  first  operation.  Solid  union 
but  slight  impaetion  of  fibula  into  medullary  cavity  of  the  tibia.  (James  S.  Stone, 
in  Annals  of  Surgery.) 


location  gradually  hypertrophied,  resulting  in  a  firm  limb. 
Rontgenograms  taken  at  intervals  showed  that  the  upper 
end  of  the  shaft  of  the  fibula  gradually  assumed  the  flattened 
inverted-cone-shaped  outlines  characteristic  of  the  normal  tibia, 


SUEGICAL  USES  OF  THE  BONE  GRAFT 


363 


Fig.  287. — Radiograph  taken  of  both  legs  nearly  two  years  after  the  removal  of 
the  shaft  of  the  tibia,  about  four  months  after  the  fibula  was  split  and  the  inner  half 
was  inserted  in  the  tibia.  There  is  a  shortening  of  exactly  4  cm.  (1^^  in).  About  one 
half  of  this  is  due  to  retarded  growth,  while  the  other  half  is  due  to  a  crowding  up  of 
fibula  into  the  medullary  cavity  of  the  tibia. 

Note  the  hypertrophy  of  the  transferred  portion  of  the  fibula  and  compare  it  ^\-ith 
the  atrophy  of  the  upper  useless  end  of  the  fibula.  Note  the  thickening  and  firm 
union  of  the  lower  divided  halves  of  the  fibula. 

The  normal  relations  of  the  malleoli  and  lower  end  of  the  tibia  are  retained.  The 
spot  from  which  the  small  sequestrum  was  discharged  is  shown  at  the  inner  side  of  the 
bone  just  above  the  lower  epiphysis  of  the  tibia.     (James  S.  Stone,  in  Annals  of  Surgery.) 


304 


BONE-CKAFT    SURGERY 


■■■mpijiy^  ...lAP- 


FiG.  288. — Radiograph  taken  in  February,  1907,  2  years  and  8  months  after  the 
removal  of  the  tibia,  9  months  after  the  preceding  radiograph.  The  tremendous 
increase  in  the  diameter  of  the  transferred  fibula  occun-ing  under  the  stimulus  of  func- 
tional use  is  strikingly  shown.  Accurate  measurenients  of  the  radiographs  show  that 
the  tibia  of  the  normal  side  has  grown  1.1  cm.  in  length  in  9  months  while  the  bone 
on  the  other  side  has  grown  .8  cm.  in  the  same  period.  In  other  words,  the  interference 
with  growth  at  the  lower  epiphyseal  line  of  the  tibia  has  been  only  ..3  cm.  in  9 
months. 

There  has  been  no  change  in  the  relations  between  the  lower  epiphyseal  lines  of  the 
tibia  and  fibula.  There  is  no  tendency  toward  the  development  of  a  talipes  varus  or 
talipes  valgus.      (James  S.  Stone,  in  Annals  of  Surgery.) 


SURGICAL  USES  OF  THE  BONE  GRAFT 


365 


again  demonstrating  the  efficacy  of  the  action  of  Wolff's  law 
in  causing  both  detached  and  undetached  bone  grafts  to  take 
on,  in  their  new  environment,  both  the  size  and  shape  which 
function  demands.      The  actual  shortening,  however,  was  3i  2  ^^^ 


Fig.  289. — By  the  kindness  of  Mr.  Robert  .Jones.     Absence  of  the  tibia 
from  osteomyelitis. 

M.  Bond's  case  illustrates  some  of  the  difficulties  and  disad- 
vantages inherent  in  this  technique. 

A  more  ideal  procedure  has  for  its  aim  complete  anatomical 


366 


BONE-GRAFT    SURGERY 


and  meehauical  restoration,  leaving  the  fibula  to  functionate  and 
supplying  the  absent  portion  of  the  tibia  by  a  free  transplant 
from  the  other  tibia.     A  portion  or  the  whole  of  the  tibia  may  be 


Fig.  290. — By  the  kiiuliie-^s  ot  Mr.  Robert  Jones.  (Same  case  as  Fig.  289.)  The 
tibia  has  been  restored  by  a  tibial  graft  which  became  broken  at  A,  and  immediately 
united. 

absent  congenitally  or  from  removal  on  account  of  osteomyelitis 
or  tumor  involvement.  During  the  past  few  years  the  pendulum 
has  swung  away  from  amputation  and  more  toward  bone  re- 


SURGICAL    USES    OF    THE    BONE    GRAFT  367 

section  in  the  treatment  of  malignant  involvement  of  bone, 
and  the  bone  graft  has  had  an  important  influence  in  making  this 
possible. 

Author's  Technique  for  the  Insertion  of  a  Graft  for  an  Absent 
Long  Bone. — The  fragment  ends  on  either  side  of  the  hiatus  are 
laid  bare  and  the  bed  for  the  graft  is  prepared,  care  being  exer- 
cised not  to  place  the  graft  in  dense  cicatricial  tissue.  The  graft 
is  inserted  into  the  fragment  ends  by  precisely  the  same  tech- 


FiG.  291. —  (Morison  in  British  Journal  of  Suroery.)  Three  months  after  Morison 
inserted  portion  of  fibula  to  restore  portion  of  shaft  of  humerus  removed  for  chondro-sar- 
coma.  Note  that  there  is  no  callous  formation.  Morison  states  that  soon  after  this 
rontgenogram  the  graft  became  entirely  detached  at  tliis  point  and  non-union  still  per- 
sisted at  his  writing.  In  the  light  of  an  extensive  experience,  it  is  believed  that  if  tlais 
graft  had  been  fixed  to  the  liumerus  fragment  by  the  inlay  method,  instead  of  by  a  metal 
plate,  union  would  have  occurred. 

nique  as  that  employed  in  applying  the  inlay  to  fractures  (see 
Chapter  IV),  except  that  a  shouldered,  or  tongued  and  grooved, 
joint  is  used  at  the  ends  of  the  graft,  to  prevent  muscle-pull 
from  shortening  the  limb  by  forcing  the  fragments  together 
before  union  occurs  (see  illustrations.  Figs.  292  and  293). 

The  graft  should  always  include  the  complete  thickness  of  the 
tibial  cortex,  periosteum,  endosteum,  and  some  marrow  sub- 
stance.    The  other  dimensions  depend  upon  the  bone  whose 


368 


BONE-GRAFT    SURGEHY 


place  it  takes  or  i\w  iiKH'haiiical  strain  to  wliicli  it  will  be  sul;- 
jected.  The  muscle-ends,  which  have  been  detached  from  the 
removed  bone,  are  attached  to  the  graft  in  theii-  normal  anatom- 


A 


TWIN  SAW 


-SINGLL  SAW 


rwiN  SAW 


Fig.  292. — Inlay  technique  for  the  insertion  of  a  tibial  graft  after  the  resection  of  a 
portion  of  the  shaft  of  a  long  bone.  The  prevention  of  the  limb  shortening  may  be 
accomplished  in  two  ways,  either  by  a  tongue  and  grooved  joint  as  indicated  at  A  or 
by  shaping  the  graft  so  that  it  is  larger  in  diameter  where  it  spans  the  bone  hiatus  and 
has  mechanical  shoulders  at  either  end,  as  indicated  by  J?,  which  is  mapped  out  in  the 
periosteum  of  the  anterior  internal  surface  of  the  tibia.  (See  drawing  to  the  right, 
also  Fig.  113.)      The  tibia  is  the  source  of  the  graft. 

ical  position  by  means  of  encircling  sutm-es  of  kangaroo  tendon. 
If  the  graft  is  inserted  to  take  the  place  of  the  end  of  a  bone,  such 
as  the  upper  end  of  the  humerus  or  the  femur,  the  upper  end 


SURGICAL    USES    OF-  THE    BONE    GRAFT 


369 


\ 

n 


should  be  placed  in  the  glenoid  or  acetabular  cavity  and  the 
capsule  sutured  around  it.  Extension  is  necessary  at  the 
shoulder  to  prevent  the  end  of  the  graft  from  pushing  through 
the  capsule.  If  the  ends  of  the  fragments  are 
small  in  diameter  and  spindle-  or  conical-shaped, 
it  is  best  to  split  them  with  the  motor  saw  into 
equal  portions  for  a  distance  of  1  or  2  in.  The 
corresponding  end  of  the  graft  is  made  wedge- 
shaped  (when  it  is  removed)  and  is  jammed 
into  the  cleft  made  in  the  end  of  its  recipient 
fragment.  The  graft  ends  are  secured  to  the 
host  fragments  by  means  of  kangaroo  tendon 
either  placed  in  drill  holes  or  wrapped  about 
the  ends  of  the  recipient  bones  and  graft  (see 
illustrative  diagrams  137  and  297).  The  soft 
structures  are  drawn  about  the  graft,  and  the 
wound  is  closed  with  a  continuous  suture  of  No. 
1  chromic  catgut. 

A  carefully  fitted  plaster-of-Paris  dressing, 
including  the  joints  on  either  side  of  the  grafted 
bone,  should  be  applied.  If  there  is  no  cause 
for  its  earlier  removal,  it  should  remain  upon 
the  limb  for  4  or  5  weeks,  at  the  end  of  which 
time  it  should  be  replaced  by  a  second  plaster 
splint  for  2  or  3  months,  or  until  the  rontgen- 
ograms  and  physical  examination  show  that 
there  has  been  a  sufficient  hypertrophy  of  the 
graft  to  be  trusted  without  support. 


A  RIB  GRAFT  FOR  THE  CLAVICLE 


Fig.  293.— Inlay 
graft  with  tongue 
and  grooved  ends 
held   in    place    with 

Tschirch  reports  a  case  of  bone  graft  of  the  ^3"^^^^°°  l^^^  °  " ' 
clavicle  in  a  girl  18  years  of  age,  in  which  it 
proved  necessary  to  replace  not  only  the  clavicle   (after  this 
bone  had  been  removed)  but  also  to  form  a   new   clavicular, 
joint.     This  was  accomplished  by  means  of  the'  right   eleventh 
rib,  which  was  resected  to  an  extent  of  13  cm.,  together  with 

24 


370 


BONE-GRAJT  SURGEKT 


Fig.  - 

with  the 

sarv  to 


SURGICAL  USES  OF  THE  BONE  GRAFT 


371 


A     —> 


Fig.  295. — By  the  kindness  of  Prof.  Kirmisson.  Loss  of  portion  of  tibia  at  A  ;  from 
osteomyelitis.  Luxation  of  head  of  fibula  and  hypertrophy  at  C  of  fibula  opposite 
hiatus  in  tibia. 


372 


BONE-GRAFT    SUKGERY 


the  entire  costal  cartilage  of  about  2.5  cm.  in  length.  The 
periosteal  covering  of  the  anterior  surface  of  the  rii)  was  re- 
moved, together  with  the  bone,  whereas  the  periosteum  of  the 
posterior  costal  surface,  which  is  applied  to  the  pleura,  w^as  left 
in  position.  The  young  girl's  rib  proved  to  be  good  plastic 
material  which  readily  assumed  and  retained  the  desired  shape. 


TWIN  SAW 
Fig.  296. — Illustrates  technique  in  case  of  which  Figs.  298  and  299  are  rontgenograms. 


Holes  were  drilled  near  the  end  of  the  rib  and  in  the  acro- 
mial process  of  the  scapula.  This  end  of  the  rib  was  then 
united  by  means  of  a  silver  wire  to  the  acromial  process.  Finally, 
the  whole  rib  graft  was  surrounded  by  muscle-tissue,  except 
the  costal  cartilage.  The  post-operative  course  was  very 
favorable.  A  good  cosmetic  result  was  obtained,  and  from  the 
functional  point  of  view  the  outcome  was  ideal. 


SURGICAL    USES    OF    THE    BONE    GRAFT  373 

BONE  GRAFT  FOR  THE  RADIUS 

In  the  case  of  a  young  woman  suffering  from  sarcoma  of  the 
distal  fragment  of  the  radius,  Walther  performed  a  resection, 
followed  by  substitution  for  the  defect  by  a  bone  fragment  from 
the  proximal  end  of  the  fibula.  The  patient  made  a  good 
recovery  and  was  enabled  to  make  use  of  her  hand,   about  2 


Fig.  297 


-Illustrates   completion   of  technique   with   tibial   graft   held  in   place 
with  kangaroo  tendon. 


months  later,   with  almost   normal  motility  of  the  wrist  and 
fingers. 

Rovsing  reported  a  case  of  sarcoma  of  the  internal  condyle 
in  which  a  resection  of  the  lower  end  of  the  femur  was  performed 
and  a  temporary  insertion  of  a  piece  of  humerus  was  applied, 
articulating  with  the  tibia,  in  order  to  preserve  the  length  and 
form  of  the  leg  w^hile  the  patient  was  under  observation  for  a 


374 


BONE-GRAFT    SURGERY  • 


recurrence.  No  recurrence  having  taken  place  at  the  end  of  2\i 
months  the  dead  humerus  was  replaced  by  a  femur  newly  ampu- 
tated from  another  individual,  after  freshening  the  upper  end 
of  the  tibia.     The  patient  made  a  good  recovery,  was  free  from 


\ 


A3*-. 


)   / 


Fig.  298. — Loss  of  the  central  portion  of  the  metacarpal  of  the  index-finger  from 
osteomyelitis,  no  periosteal  regeneration  after  1  year.  Absent  bone  shaft  restored  by 
bone  graft.      (See  Fig.  299.) 

recurrence  1  year  after  the  first  operation,   able  to  walk  with 
a  cane,  and  in  a  condition  to  work. 

This  case  is  illustrative  of  an  important  principle,  i.e.,  the 
support  and  the  prevention  from  shortening  of  a  limb  from  which 


SURGICAL  USES  OF  THE  BONE  GRAFT 


375 


a  malignant  bone  growth  has  been  removed,  the  hiatus  being 
suppUed  by  a  temporary  graft  until  sufficient  time  for  observa- 


'# 


V   ^.-^ 


I  __  ^ 


m  f ' 


YiG    099 —Same  case  as   TiK-  2'.)S,  after  missing  portion  of  metacarpal  bone  has  been 
'   restored  by  author  with  a  tibial  graft.     See  Fig.  297  for  diagram  of  technique. 

tion  as  to  a  recurrence  has  elapsed,  or  until  suitable  material  for 
a  permanent  joint  graft  can  be  obtained. 


376 


BONE-GRAFT  SURGERY 
SPINA  VENTOSA 


Advanced  cases  of  spina  ventosa  are  best  treated  by  removal 
of  the  diseased  diaphyseal  bone  and  periosteum  and  the  substitu- 
tion of  a  bone  transplant  with  its  periosteum.     Damage  to  the 


Fig.  300. — Complete  congenital  absence  of  the  radius.  Contraction  of  either  the 
extension  or  flexion  of  the  forearm  caused  even  more  marked  adduction  of  the  hand  on 
the  forearm  than  shown  in  this  photograph,  on  account  of  lack  of  skeletal  support  of  the 
radius. 

The  author  has  met  this  condition  in  two  ways,  either  by  restoring  the  complete 
radius  (see  Figs.  301  and  302)  or,  preferably,  by  mortising  a  graft  into  the  radial  side  of 
ulna  (at  the  junction  of  its  middle  and  lower  third)  and  the  scaphoid  bone.  The  latter 
graft  functionates  better  and  benefits  by  the  distal  growth  of  the  epiphyseal  cartilage 
of  the  upper  end  of  ulna.      (See  Figs.  303  and  304.) 

epiphyseal  cartilages,  which  in  the  metacarpal  bones  are  situated 
at  their  distal  and  in  the  phalangeal  bones  at  their  proximal 
end,  should  be  carefully  avoided.  The  bone  defect  is  replaced 
by  a  graft   taken  from  the  crest   of  the  tibia   of  the  same 


SURGICAL    USES    OF    THE    BONE    GRAFT 


377 


patient.  If  phalangeal  or  metacarpal  stumps  are  not  too 
short,  the  graft  is  mortised  or  inlaid  into  them.  Strong  traction 
should  be  applied  to  the  distal  end  of  the  finger  while  the  graft 


Fig.  301.— Same  as  Fig.  302. 


Fig.    302. — Complete    absence  of 
radius  restored  by  a  tibial  graft. 


is  being  inserted  tightly  into  place.  A  snugly  fitting  plaster 
spUnt  should  be  applied  to  the  finger  and  the  hand  and  allowed 
to  remain  in  place  for  8  to  12  weeks.  The  resistance  of  cortical 
bone  graft  to  tubercular  infections  and  to  attenuated  infections 


378 


BONE- GRAFT   SURGERY 


of  other  varieties  has  been  repeatedly  proved  by  the  author. 
As  a  rule,  the  functional  and  cosmetic  results  are  excellent.  The 
motion  in  the  joints  of  children  gradually  returns  by  use. 


Fig.  303. — Complete  congeni- 
tal absence  of  the  radius.  A 
tibial  bone  graft  was  mortised 
into  ulna  and  scaphoid  bones  2 
weeks  before. 


Fig.  3  04.  —  Rontgenogram 
taken  4  months  later.  The  hand 
is  supported  perfectly  and  the 
result  has  been  most  satisfactory. 


This  treatment  is  also  applicable  to  the  bones  of  the  foot,  as 
well  as  to  the  carpal  bones. 


OSTEITIS  FIBROSA   CYSTICA 


The  case  of  osteitis  fibrosa  cystica  of  the  humerus  described 
in  Murphy's  CUnics,  vol.  ii.,  No.  5,  where  a  bone  graft  was  used 


SUEGICAL    USES    OF    THE    BONE    GRAFT 


379 


to  supply  a  deficiency  caused  by  the  removal  of  the  cystic 
portion,  is  well  illustrated  by  the  rontgenograms  taken  from 
that  publication  (Figs.  201-205). 

The  patient  was  a  girl,  10  years  of  age,  presenting  a  typical 
condition  of  osteitis  fibrosa  cystica  of  the  humerus.  She  had 
undergone  mercurial  treatment,  with  negative  result. 


Fig.  305. — Drawing  illustrating  author's  technique  for  congenital  absence  of  the  radius. 
The  tibial  graft  is  mortised  into  the  ulna  and  scaphoid  bones. 

Technique  of  Operation. — ' '  An  incision  was  made  along  the 
anterior  border  of  the  bicipital  groove,  extending  down  below 
the  attachment  of  the  deltoid.  The  muscular  attachments 
were  separated  and  retained  in  position  for  recognition.     The 


380 


BONE-GRAFT    SURGERY 


hone  was  then  freed  from  all  its  surr()uiuiin<2;  tissue,  leaving 
the  periosteum  attached  to  the  excised  bone.  Six  and  a  half 
inches  were  excised,  including  the  head  and  epiphyseal  line. 
A  T.'i-in.  transplant  was  prepared  from  the  crest  of  the  tibia; 
the  periosteum  was  retained.  This  transplant  measured  %  X  M 
in.  The  medulla  of  the  remaining  portion  of  the  shaft  of 
the  humerus  was  reamed  out  and  the  transplant  was  in- 
serted for  -yi  in.     A  nail  was  then  passed  through  a  drill  hole 


Fig.  306. — A  indicates  cystic  involvement  of  phalanx  with  marked  lateral  deviation 
of  the  finger.  This  type  of  case  can  be  most  satisfactorily  treated  by  the  implantation 
of  a  bone  to  replace  the  cystic  bone,  and  cannot  be  managed  by  any  other  method. 

transversely,  to  prevent  it  from  imbedding  itself  more  deeply. 
The  upper  end  of  the  implant  was  inserted  into  the  glenoid 
cavity,  and  the  capsule  was  accurately  sutured  around  it. 
The  muscle  ends  were  then  attached  by  an  encircling  suture 
around  the  implant  in  about  their  normal  anatomical  position. 
The  wound  was  closed  by  a  deep  row  of  catgut  sutures  and 
superficial  horsehair  sutures.  The  arm  was  dressed  in  abduction 
at  about  a  right  angle  to  the  body.     A  Buck's  extension  was 


SURGICAL    USES    OF    THE    BONE    GRAFT 


381 


applied  to  the  forearm  and  a  10-lb.  weight  attached  with 
a  line  running  from  a  pulle3^  This  was  to  prevent  muscular 
contractions  during  the  period  of  regeneration,  which  would 
probably  have  driven  the  upper  end  of  the  bone  through  the 
capsule.     It  was  kept  on  for  5  weeks." 

Result. — "There  was  complete  primary  union,  and  at  the 
end  of  5  weeks  the  humerus  appeared  on  palpation  to  be  as 
large  as  the  normal  humerus.     The  patient  had  good  voluntary 


Fig.  307. — Restoration  of  the  first  metacarpal  bone  with  a  tibial   graft.     The  meta- 
carpal bone  was  destroyed  by  tuberculosis.      (Katzenstein.) 

motion.  The  position  to  which  she  could  extend  the  arm  when 
she  left  the  hospital,  5  weeks  after  operation,  showed  how  much 
abduction  was  produced  by  the  deltoid  and  supinator  muscles. 
A  subsequent  rontgenogram  shows  how  completely  this  bone 
regenerated,  not  only  in  the  part  outside  the  capsule,  but  also 
how  it  has  filled  in  within  the  capsule.  It  also  shows  the 
periosteum  remaining  intact  and  not  becoming  ossified  even 
after  this  date,  so  that  it  would  appear  in  this  case  that  the 


382 


BONE-GRAFT   SURGERY 


Fig. 


308. — A  tuberculous  second  metacarpal  hone  removed  and  restored  with  a 
tibial  graft.      (Katzenstein.) 


Fig.  309. — A  case  of  drop  wrist  from  anterior  poliomyelitis  and  complete  paralysis 
of  the  extensor  muscles  of  the  forearm.  Any  attempt  to  use  the  hand  caused  the  unap- 
posed  muscles  of  the  anterior  forearm  to  acutely  flex  the  hand,  and  therefore  a  complete 
loss  of  power  to  flex  the  fingers.      (See  Figs.  310  and  311.) 


SUEGICAL  USES  OF  THE  BONE  GRAFT 


383 


periosteum  on  the  transplant  is  a  detriment  rather  than  an 
advantage.  The  series  of  rontgenograms  shows  the  progress 
of  bone  development.  Extension  from  the  living  periosteum 
below  was  the  most  important;  next,  from  the  medulla.  This 
rapidly  shot  upward  around  the  transplant  to  the  capsule  of  the 
joint,  and  later  into  the  capsule.  She  can  now  abduct  her  arm 
to  a  right  angle  in  extension,  and  flexion  is  likewise  complete,  so 
that  she  does  not  know  any  serious  operation  has  been  done  on 
her  arm  so  far  as  its  usefulness  is  concerned." 


Fig.  310. — The  illustration  indicates  the  shape  and  position  of  the  bone  graft  in  its 
application  to  support  a  paralytic  drop  wrist  in  extension  to  restore  the  grasp  of  the 
flexors  of  the  fingers.      (Author's  technique.) 


TRANSPLANTATION  OF  COMPLETE  SMALL  BONES 

The  smaller  long  bones  can  be  grafted  in  their  entirety,  with 
both  articular  surfaces,  as  demonstrated  by  Lexer;  and  in  the 
event  of  a  destructive  lesion  (from  trauma  or  other  cause)  of 
a  phalanx  with  loss  of  function,  one  is  able  to  obtain  a  phalanx 
from  an  amputated  limb,  or  autoplasty  can  be  done  by  removing 
a  toe  or  a  segment  of  a  rib  cartilage.  Formerly,  fingers  thus 
affected  were  amputated. 


A  HETEROPLASTIC   GRAFT  FOR  TOTAL  ABSENCE   OF  FIBULA 

Kiittner  has  reported  a  case  of  complete  absence  of  the  fibula, 
for  which  the  fibula  of  a  Java  monkey  was  implanted.     The  bone 


384 


BONE-GRAFT    SURGERY 


healed  in  without  reaction  of  any  kind  and  showed  not  the 
shghtest  trace  of  al)S()ri)tion,  and  the  e])iphyseal  hne  of  the 
implanted  segment  is  well  i:>reserved.     He  also  ol)serves  that  in 


Fig.  311. — Rontgenogram  of  case  (Fig.  309)  after  tibial  bone  graft  had  been  inserted 
into  radius  and  onto  posterior  surface  of  the  os  magnum.  For  diagrammatic  drawing  of 
author's  technique,  see  Fig.  310.  The  grasp  of  the  hand  was  almost  completely 
restored  by  the  mechanical  support  of  hand  in  extension. 

children  transplantation  from  young  monkeys  is  especially  well 
adapted  to  replace  entire  bones. 

TRANSPLANTATION  OF  JOINTS 

To  Lexer  is  due  the  credit  of  the  first  joint  transplantation, 
which  w'as  an  outgrowth  from  his  cartilage  and  bone  trans- 


SURGICAL    USES    OF    THE    BONE    GRAFT 


385 


plantations.  It  necessarily  follows  that  if  one  can  perform 
homoplasty  with  large  segments  of  long  bones,  it  is  possible  to 
transplant  the  bone  with  its  articular  surfaces.  Lexer's  earliest 
experiment  in  this  field  was  attempted  in  November,  1907.  It 
occurred  in  a  case  of  a  defect  in  the  tibia  involving  the  entire 
upper  third,  including  the  articular  surface,  from  a  central 
sarcoma.  The  earlier  procedure  in  similar  cases  was  to  engage 
the  lower  end  of  the  femur  into  the  tibia  by  boring,  thus  permit- 
ting union  between  the  bones  with  considerable  shortening  of 


A  B 

Fig.  312. — To  illustrate  technique  for  ankylosing  the  shoulder.  .-1.  The  cartilage 
from  the  glenoid  fossa  and  acromion  process,  and  contiguous  surface  of  the  head  of  the 
humerus,  is  removed.  B.  The  humeral  head  is  placed  in  the  glenoid  fossa  and  a  bone- 
graft  peg  inserted  into  it  through  the  acromion  process. 

the  limb.  In  order  to  obviate  the  latter  result,  and  if  possible 
to  restore  the  mobile  functions  of  the  joint,  a  similar  portion  of 
the  tibia  was  removed  from  a  freshly  amputated  limb  and  im- 
planted with  its  articular  cartilage  and  periosteum.  Then  the 
thought  arose  to  advance  a  step  farther.  If  it  were  possible 
to  achieve  healing  of  this  large  segment  of  bone  with  its  articular 
extremity,  like  success  might  be  attained  by  transplanting  the 
articular  surfaces  for  the  repair  of  joints.  This  idea  was  im- 
mediately carried  into  action,  as  there  was  at  hand  a  freshly 


386  BONE-GRAFT   SURGERY 

ainputatcHl  liiiil),  and  on  uunierous  occasions  attempts  had  been 
made  to  use  other  tissues  and,  lately,  fat  to  mobilize  joints. 

After  resection  of  the  synovial  sac  and  the  articular  surfaces 
of  the  tibia  and  femur,  with  their  attachments,  the  crucial  liga- 
ments of  considerable  thickness  were  dissected  and  implanted 
in  their  entirety  over  the  previously  prepared  defect.  The  first 
method  has  been  called  ''half-joint  transplantation"  and  the 
second,  'Svhole-joint  transplantation."  By  half-joint  trans- 
plantation is  implied  transplantation  of  bony  extremities, 
utilizing  their  articular  menil)rane  as  nuich  as  possible,  while  in 
whole-joint  transplantation  is  meant  the  imbedding  of  long 
bones  with  both  articular  surfaces.  This  work  was  successfully 
carried  out  by  others  (Kijttner,  Rovsing,  Wolff,  Enderlen,  etc.), 
as  well  as  by  Lexer.  The  source  of  the  material  has  been  freshly 
amputated  limbs.  The  use  of  material  from  the  fresh  cadaver 
has  been  discontinued :  first,  because  of  the  difficulty  in  obtaining 
sterile  tissues  from  the  morgue;  and  second,  because  fibrous 
encapsulation  took  place  in  one  case  of  knee  transplantation. 

Of  six  cases,  in  two  the  knee-joints  from  amputated  extremi- 
ties were  transplanted  with  the  internal  ligaments  intact,  to  re- 
place knee-joints  resected  for  bony  ankylosis.  The  functional 
result  in  these  cases  has  not  yet  been  determined.  In  one  of  them, 
how^ever,  it  was  demonstrated  by  chiselling  off  a  piece  of  the 
graft  on  the  occasion  of  a  secondary  operation  to  relieve  anky- 
losis of  the  patella  to  the  femur  that  there  was  firm  union  of  the 
transplanted  surface,  through  which  new  blood-vessels  were 
growing.  In  another  case,  the  entire  upper  end  of  a  tibia  from 
an  amputated  extremity  was  grafted  to  replace  a  corresponding 
piece  of  bone  removed  for  sarcoma;  the  patellar  fragment  was 
sewed  to  the  new  tibial  tuberosity.  There  was  complete  healing 
and  excellent  functional  result.  A  good  result  is  promising 
in  the  fifth  case,  in  which  the  lower  end  of  a  femur,  with  one 
condyle  shaped  to  articulate  in  the  glenoid  fossa,  was  sub- 
stituted for  the  upper  two-thirds  of  a  humerus  removed  for 
sarcoma;  a  piece  of  the  fibula  was  used  as  an  intramedullary 
splint  to  unite  the  graft  with  the  shaft  of  the  humerus.     In  the 


SURGICAL    USES    OF    THE    BONE    GRAFT  387 

sixth  case,  the  first  phalanx  of  the  second  toe  of  an  amputated 
foot  was  used  to  replace  the  first  phalanx  of  a  finger.  Healing 
was  perfect  and  the  joints  are  movable. 

In  two  cases  of  bony  ankylosis  of  the  elbow-joint,  Buchmann 
implanted  an  entire  closed  joint  into  the  wound  of  the  resected 
bones,  the  graft  being  the  first  metatarso-phalangeal  joint, 
which  permits  a  fairly  wide  range  of  extension  and  flexion.  By 
means  of  this  transplantation,  the  mobility  of  the  elbow-joint 
may  be  restored.  Bone  suture  is  not  necessary  in  this  operation. 
The  joint  between  the  eminentia  capitata  humeri  and  the  radial 
head  should  be  widely  resected.  Dressings  are  first  applied  in 
extension,  followed  2  weeks  later  (not  before)  by  dressings  in 
the  flexed  position.  Active  and  passive  movements  are  possible, 
without  pain,  in  the  transplanted  joint,  in  the  range  of  motion 
permitted  by  the  contracted  muscles.  Buchmann  states  that 
this  new  method  of  treating  bony  ankylosis  of  the  elbow-joint 
may  also  be  found  useful  in  the  treatment  of  flail  joints,  and 
that  the  resection  of  the  patient's  first  metatarso-phalangeal 
joint  exerts  no  injurious  effect  upon  the  function  of  the  foot. 
The  wound  in  the  foot  is  closed  by  sutures  and  allowed  to  heal. 
Buchmann's  patients  were  young  girls  14  and  19  years  of  age. 

Kiittner  has  further  worked  out  the  utilization  of  the  fresh 
cadaver,  and  reports  successes  in  half -joint  transplantation. 
He  employed  homoplastic  material  under  great  difficulties,  and 
in  fact  performed  heteroplasty  with  tissues  in  which  the  albumen 
is  closely'  related  to  that  of  man.  i.e.,  from  the  ape. 

Autoplasty  is  applicable  only  to  the  finger  joints,  as  the  toe 
joints  can  be  substituted  for  them. 

That  massive  bone  sections  and  entire  joint  surfaces  may  be 
thus  substituted  and  made  to  unite  is,  in  itself,  a  very  important 
advance.  ''It  affords  the  hope  that  only  the  development  of 
the  technique  will  be  needed  to  establish  such  substitutions  as 
regular  surgical  procedures." 

In  certain  cases  of  luxation  fracture  it  is  necessarj^  to  remove 
the  broken  and  luxated  joint  segments  or  entire  articular  ends, 
because  the  fragments  are  considerably  displaced  and  entirely 


388  BONE-GRAFT   SURGERY 

detached  from  their  surroundings.  In  case  of  joint  fragments 
with  well-preser\'ed  cartilage,  when  the  bone  is  not  crushed  or 
spUntered,  reimplantation  may  be  given  a  trial.  The  prospects 
of  healing  are  especially  favorable  in  such  autoplastic  grafts,  in 
that  very  good  and  permanent  results  are  obtained.  Lexer  has 
succeeded  even  by  homoplastic  implantation  of  articular  bone 
ends.  The  so-called  half-joint  transplantations,  where  the 
segments  can  be  surrounded  by  the  preserved  capsule,  are  the 
most  favorable.  All  grafts  require  in  the  first  place  a  rapid 
healing  with  the  surrounding  tissues  and  ])ronipt  nourishment 
from  the  same.  In  those  defects  due  to  operative  removal  of 
sarcomatous  bone  segments,  the  wound  cavities  are  surrounded 
by  fresh  tissue  which  are  very  favorable  to  the  early  nourishment 
of  the  graft.  After  injuries,  the  nutritional  conditions  are  not  so 
favorable,  especially  in  old  cases  where  the  cicatricial  tissue  is 
very  poor  for  the  nutrition  of  the  graft;  while  in  recent  cases 
(after  the  end  of  the  second  week,  at  the  earliest)  the  wound 
surfaces  are  improperly  nourished,  infiltrated  with  blood  and 
contaminated  with  necrotic  tissue  constituents.  Nevertheless, 
Lexer  regards  an  attempt  as  justified  because  he  argues  that,  at 
the  worst,  the  result  after  the  onset  of  necrosis  is  the  same  as  after 
the  immediate  removal  of  the  articular  segment  at  the  first 
operation. 

The  first  of  his  two  cases  reported  occurred  in  a  young 
laborer  who  came  under  treatment  with  an  untreated  oblique 
fracture  of  2  months'  standing  at  the  lower  end  of  the  left 
humerus,  with  ankylosis  of  the  elbow  in  rectangular  flexion 
and  pronounced  valgus  position.  The  fragment,  including 
the  external  condyle,  together  with  the  trochlea  and  the  capitellar 
eminence,  w^as  much  displaced  in  the  anterior  and  mesial  direc- 
tion, and  was  imbedded  throughout  in  scar  tissue.  After 
exposure,  it  was  seen  to  be  disconnected  with  the  muscle  and  the 
capsule,  so  that  it  could  be  taken  out.  After  freshening  the 
fractured  surface  of  the  humerus,  it  was  replaced  in  the  proper 
position  and  fixed  with  a  horn  peg.  After  the  wound  had  healed, 
the  patient  left  the  clinic,  because  he  would  not  consent  to 


SURGICAL    USES    OF    THE    BONE    GRAFT  389 

exercise  of  the  joint.  It  is  noteworthy  that  a  good  result  was 
obtained  without  any  after-treatment.  Six  months  after  his  dis- 
charge, extension  was  possible  up  to  150  degrees;  flexion  at  105 
degrees.  Pronation  and  supination  were  not  inhibited.  The 
patient  was  well  able  to  work  as  a  carrier  of  heavy  sacks. 

Rontgenograms  showed  a  properly  placed  well-preserved 
joint  surface,  with  slight  bone  proliferation  in  the  region  of  the 
brachial  muscles. 

The  second  patient  was  a  woman  who  had  suffered  a  severe 
luxation  fracture  of  the  humeral  head,  in  a  fall  from  a  carriage, 
with  extensive  longitudinal  splitting  in  the  region  of  the 
greater  tuberosity.  The  fracture  line  passed  obliquely  behind 
the  surgical  neck.  Reduction  being  impossible,  exposure  of  the 
broken  head  was  made  at  the  beginning  of  the  third  week,  by 
way  of  the  axilla.  The  articular  segment  (4  cm.  in  its  largest 
diameter)  was  found  to  be  far  displaced  to  the  inside,  and  rotated 
downward  at  a  right  angle.  There  was  no  connection  with  the 
muscle  insertions  and  the  joint  capsule;  only  a  few  ragged 
muscular  insertions  were  left  on  the  splinters  of  the  greater 
tuberosity;  these  splinters  were  so  badly  crushed  that  they  were 
removed.  The  wound  cavity  was  well  trimmed,  with  removal 
of  all  tissue  shreds,  remnants  of  tendons,  muscles,  etc.  The 
articular  head,  the  cartilage  of  which  appeared  intact  through- 
out, was  then  united  so  tightly  with  the  oblique  fragment  of  the 
diaphysis,  by  means  of  a  few  wire  sutures,  that  reduction  could 
be  accomplished  according  to  the  usual  method.  The  joint 
capsule  was  then  sutured  to  the  periosteum  near  the  head. 
Everything  healed  well,  and  the  detached  muscle  insertions 
became  reunited  to  the  bone  through  scar  tissue,  so  that  the 
loss  of  active  function  was  not  great.  At  any  rate,  the  outcome 
was  better  than  after  resection,  as  is  usually  performed  in  these 
cases. 

Perthes  adopted  a  similar  procedure  in  a  case  of  long-standing 
fracture  of  the  humeral  head  with  simultaneous  posterior  luxa- 
tion of  the  head.  The  luxated  head  segment  was  removed  in  a 
general  way,  but  the  cartilaginous  joint  segment  was  sawed  off 


390  BONE-GRAFT    SURGERY 

and  was  grafted  on  the  end  on  the  diaphyseal  stump,  where  it 
healed  in  good  position.  Active  mobility  in  the  shoulder-joint 
was  still  slight,  but  not  lost. 

Lasse,  in  two  cases  of  articular  fracture  of  the  elbow-joint  in 
children  (in  which  the  trochlea  was  completely  broken  off  and 
had  become  rotated  so  that  the  fractured  surface  of  the  humerus 
was  confronted  by  the  cartilaginous  articular  surface)  opened 
the  joint,  replaced  the  detached  trochlea  (which  was  separated 
from  all  connections  with  the  articular  capsule  and  synovial 
membrane),  and  fixed  it  to  the  humerus  by  means  of  small  tacks. 
Unhiterrupted  healing  with  ideal  function  of  the  elbow-joint 
resulted. 

According  to  Lasse's  experience,  the  outcome  of  these  opera- 
tions is  primarily  governed  by  two  factors:  (1)  careful  and 
complete  detachment  of  the  unfavorably  displaced  distal 
fragment.  This  detachment  can  hardly  be  carried  too  far. 
Lexer,  as  well  as  Lasse,  in  certain  cases  entirely  detached  this 
distal  fragment.  Care  should  be  taken  to  preserve  the  periosteum 
of  this  bone  fragment,  as  far  as  possible.  (2)  On  the  other 
hand,  it  is  necessary  to  remove  very  carefully  with  the  scissors 
and  scalpel  any  callus,  capsular  remnants,  etc.,  which  interfere 
with  the  proper  position  of  the  fragment.  It  is  in  this  way  only 
that  it  is  possible  to  avoid  a  displacement  of  the  fragment, 
and  to  provide  for  its  sufficient  nutrition  by  imbedding  it  in 
fresh  normal  muscle-  or  tendon-tissue,  instead  of  the  poorly 
nourished  cicatricial  tissue.  This  probably  accounts  for  the 
absence  of  even  a  partial  necrosis  of  the  detached  bone  seg- 
ments. It  is  not  always  necessary  to  detach  all  connections 
with  the  surrounding  structures.  The  detaching  and  the 
removal  of  tissue  should  only  be  continued  until  the  proper  posi- 
tion can  be  reestablished  and  maintained  without  difficulty. 
As  a  rule,  this  fixation  can  be  accomplished  by  simply  wedging 
the  fragment  in  place  in  such  a  way  that  the  distal  fragment  is 
moulded  and  placed  into  a  groove  of  the  proximal  fragment 
(rarely  the  other  way  around).  Circumstances  alter  cases,  and 
the  available  material  should  be  utilized  as  well  as  possible. 


SURGICAL  USES  OF  THE  BONE  GRAFT  391 

BONE  GRAFT  FOR  BONE  DEFECT  OF  SKULL 

Various  methods  have  been  devised  for  employing  the  bone 
graft  to  restore  the  protecting  skull,  when  a  portion  of  it  has 
been  lost.  Homoplastic  and  autoplastic  giafts  have  been  used. 
The  latter  type  of  graft  should  always  be  employed  when 
possible.  The  outer  table  of  the  bone  near  the  aperture  has  been 
split  from  the  inner  table  and  swung  over  to  cover  the  opening, 
the  overlying  soft  structures  being  undetached.  As  pointed 
out  elsewhere,  the  pedunculated  graft  has  doubtful  advantages 
over  the  free  graft,  and  if  the  bony  outer  table  is  not  too  thin, 
the  simpler  technique  of  the  free  transplant  should  be  chosen. 
In  children,  where  the  skull  is  so  thin  that  even  pedunculated 
skin-covered  flaps  cannot  be  removed,  periosteal  bone  flaps 
should  be  transfen-ed  from  the  tibia. 

Ropke  has  suggested  the  resection  of  a  portion  of  the  wing  of 
the  scapula  so  that  the  graft  be  covered  with  periosteum  on  both 
surfaces. 

Technique  of  Inserting  Bone  Graft  for  Skull  Defect. — A  scalp 
flap  about  }s  to  ;^4  in.  larger  on  every  side  than  the  skull  opening, 
is  turned  back.  The  separation  of  the  scalp  and  the  dura  is 
carefully  done.  If  the  dura  is  thickened  and  adherent  to  the 
brain  cortex,  it  should  be  dissected  away,  providing  cortical 
symptoms  have  appeared.  The  bony  edge  of  the  aperture  is 
freshened  by  drilling  several  holes  about  }i  to  ^  3  in.  from  the  edge 
of  the  opening,  with  the  ]Martel  attachment  to  the  author's  motor. 
The  thickness  of  the  skull  is  then  measured  and  a  thin  strip  of 
bone  is  removed  all  around  the  edge  of  the  opening  with  the 
motor  saw  protected  by  a  proper  sized  washer.  These  saw- 
cuts  should  be  made  markedly  bevelled.  Additional  protection 
to  the  dura  from  the  saw  can  be  furnished  by  slipping  a  thin 
piece  of  ivory  under  the  bony  edge  which  the  saw  is  cutting. 

All  the  dimensions  of  the  operation  are  then  carefully  taken 
with  cahpers  or  compasses,  and  are  transferred  to  the  upper  por- 
tion of  the  anterior  internal  surface  of  the  tibia  selected  as  the 
source  of  the  graft  material.  The<exact  size  and  contour  of  the 
graft  is  outhned  in  the  periosteum  with  the  point  of  a  scalpel. 


392 


BONE-GRAFT    SURGERY 


from  the  calipoi-  nieasurcmonts.  The  graft  is  removed  with  the 
author's  small  saw,  the  cuts  being  bevelled  the  same  as  those  at 
the  edge  of  the  skull  opening,  so  that  the  transplant  will  rest 
firmly  on  the  skull  and  cannot  be  driven  down  upon  the  brain 
beneath.  The  graft  is  held  in  place  by  two  or  three  ligatures  of 
medium  kangaroo  tendon  placed  in  corresponding  drill  holes  in 
the  edges  of  the  graft  and  skull  opening.  The  upper  end  of  the 
tibia  is  selected  rather  than  the  lower  portion  because  its  cortex 
is  thinner  and  its  surface  flatter  and  broader.     A  graft  covered 


Fig.  313. — The  upper  dark  area  (X )  w  ht,  liUed  by  a  disc  of  bone,  the  lower  hght  area  by 
chips.      (Rutherford  Morison  in  British  Jour,  of  Surgery.) 

on  both  sides  with  periosteum  may  be  obtained  by  the  same 
technique  from  the  scapula.  A  rib  also  has  been  utilized  for 
the  purpose. 

If  the  dura  is  lacking,  the  brain  should  be  covered  by  a  thin 
sheet  of  collodion  (Prime)  or  Cargile  membrane  just  before  the 
transplant  is  fixed  in  place.  The  scalp  is  closed  in  the  usual  way. 
This  technique  is  applicable  to  all  bone  defects  of  the  head  such 
as  mastoid  depression  following  drainage  operations,  etc. 


SURGICAL  USES  OF  THE  BONE  GRAFT  393 

DEFECTS  OF  THE  NOSE 

Rhinoplasty   by   Means   of   a   Finger   as   a   Transplant. — 

Defects  of  the  nose  were  previously  restored,  as  a  rule,  by  a 
reflection  of  periosteal  and  bony  flaps  from  the  forehead  or  cheeks 
and  have  the  great  disadvantage  of  leading  to  extensive  scars  and 
possible  necrosis.  Gold,  silver  wire,  and  other  materials  have 
been  used  in  forming  a  framework  for  the  new  nose,  but  they 
should  be  discarded  for  this  purpose  because  of  the  fact  that  as 
foreign  substances  they  give  rise  to  irritation  and  sooner  or  later 
have  to  be  removed.  The  inj  ection  of  paraffine  is  not  liable  to  be 
permanent,  and  does  not  give  a  satisfactory  framework.  In  a 
recent  case  of  the  author's  when  a  tibial  bone  graft  was  inserted, 
paraffine  which  had  been  injected  5  years  previously  had  entirely 
disappeared,  leaving  a  deformity  worse  than  the  original. 

Animal  bone  has  been  suggested  by  Sir  Watson  Cheyne  for 
this  purpose,  but  should  not  be  employed  on  account  of 
its  unreliability. 

Finney  (Surg.  Gyn.  and  Ohstet.,  June,  1907)  used  success- 
fully a  finger  for  material  to  reconstruct  a  nose  that  had  been 
lost  as  a  result  of  congenital  lues.  The  bony  support  of  the  nose, 
including  the  septum,  had  been  entirely  destroyed.  The 
integument  remained,  but  was  retracted  and  distorted.  In 
place  of  the  nose,  there  was  a  depression. 

'^The  ring-finger  of  the  left  hand  was  selected  as  being  the 
one  best  adapted  for  this  purpose  and  the  one  perhaps  least 
missed  from  the  hand.  The  nail  and  matrix  were  completely 
removed,  and  the  dorsum  of  the  finger,  up  to  the  distal  end  of  the 
first  phalanx,  was  denuded  of  skin.  The  tip  of  the  finger, 
throughout  its  entire  circumference,  was  also  denuded  of  skin 
for  about  the  distance  of  1  cm.  from  the  end,  leaving  the  distal 
phalanx  exposed,  although  not  completely  so.  All  bleeding  was 
stopped.  The  skin  covering  the  nose,  which  was  retracted  and 
deformed,  owing  to  cicatricial  contraction,  was  then  carefully 
freed  from  its  attachments  below,  without  making  any  ex- 
ternal scar.     The  skin  of  the  nose  was  then  stretched  carefully 


394  BONE-GRAFT    SURGERY 

and  th()r()U«>;lily  Ijy  inserting  the  rounded  end  of  a  blunt  instru- 
ment into  the  nasal  opening,  in  ordei-  to  give  as  much  covering 
as  possible  for  the  new  nose.  The  soft  parts  were  next  freed 
from  the  nasal  process  of  the  frontal  bone,  from  within  the  nose, 
by  a  knife  or  instrument  passed  up  through  the  nasal  opening. 
The  inner  surface  of  the  skin  forming  the  nasal  covering  was 
denuded  on  the  inner  side  in  the  middle  line,  in  order  that  a  raw 
surface  might  be  opposed  to  the  denuded  surface  of  the  dorsum 
of  the  finger,  described  above,  which  was  then  inserted  into  the 
nasal  opening  until  the  tip  of  the  distal  phalanx  rested  upon  the 
nasal  process  of  the  frontal  bone.  The  finger  was  held  in  place 
by  sutures  through  the  free  border  of  the  tip  of  the  nose  and  the 
edge  of  the  skin,  over  the  dorsum  of  the  first  phalanx.  Thus 
raw  surfaces  were  opposed  when  it  was  desired  to  secure  new 
blood  supply  for  the  finger,  namely,  on  the  tip  and  dorsum,  while 
skin  covered  the  palmar  surface  of  the  finger,  which  formed  the 
inner  lining  of  the  nose.  The  hand  was  held  in  this  position 
by  adhesive  strips  and  plaster-of-Paris  bandages  for  2  weeks, 
whereupon  the  finger  was  disarticulated  at  the  metacarpo- 
phalangeal joint,  and  left  for  another  week,  at  the  end  of  which 
time  the  tissues  in  the  middle  line  over  the  nasal  spine  of  the 
superior  maxilla  were  split,  the  finger  flexed  to  a  right  angle  at  its 
proximal  phalangeal  joint,  and  the  free  end  of  the  first  phalanx 
then  inserted  into  this  opening  and  held  there  by  stitches 
through  the  soft  parts.  The  first  phalanx  then  formed  the 
columna  of  the  nose,  while  the  second  and  third  phalanges 
formed  a  very  satisfactory  support  for  the  dorsum.  Later, 
smaller  operations,  under  cocaine,  were  performed  to  improve 
the  appearance  of  the  columna,  which  of  course  was  too  large." 

Since  bone  was  not  apposed  to  bone,  the  nose  was  freely 
movable  from  side  to  side,  which  was  of  advantage  in  case  of 
injury.     The  results  were  very  satisfactory. 

Finney  recommends  that  a  piece  of  rubber  tubing  be  kept 
in  each  nostril  for  a  time  after  the  operation,  as  this  furnishes  a 
support  for  the  alse  and  prevents  undue  contraction.  Previous 
to  the  successful  results  reported  by  Finney,  attempts  to  use  the 


SURGICAL    USES    OF    THE    BONE    GRAFT 


395 


finger  by  similar  technique  for  this  purpose  had  been  made  by 
Hardie  (1875),  Sabine  (1879),  Bloxam  (1895),  Tunis  (1897),  and 
Vredena  (1902). 

The  Free  Bone  Graft  in  Correction  of  Deformities  of  the 
Nose. — Carter,  in  considering  deformities  of  the  nose,  divides 
them  into  two  classes:  (1)  ''Those  withovit  loss  of  tissue;  (2) 
those  in  which  there  has  been  more  or  less  destruction  of  the  bony 


Fig.  314. — Bone  transplantation  for  nasal  deformity.  The  central  figure  shows 
method  of  elevating  skin  and  sub-cutaneous  tissues;  the  insert  figure  shows  the  bone  in 
place.      (William  Wesley  Carter,  Medical  Record.) 


and  cartilaginous  framework  of  the  organ.  In  the  first  class,  the 
deformity  is  congenital,  acquired,  or  due  to  traumatism,"  and 
is  amenable  to  procedures  other  than  bone  transplantation. 
In  the  second  class,  where  there  is  a  deficiency  in  the  bony 
framework,  bone  grafting  is  indicated.  Cases  of  this  class  may 
be  syphihtic,  congenital,  traumatic,  or  due  to  atrophic  rhinitis. 


396 


BONE-GRAFT   SURGERY 


Fig.  .no. 


Fig.  316. 
Figs.  315  .\^•D  316. — Specific  destruction  of  entire  nose.     In  this  case  bone  from  rib 
was  first  transplanted  into  the  arm,  and  later  flap  containing  bone  was   transplanted 
to  face.     Patient  breathes  through  nose.     Condition  excellent  2  years  after  operation. 
(William  Weslej-  Carter,  in  Medical  Record.) 


SURGICAL  USES  OF  THE  BONE  GRAFT  397 

Technique  of  Carter's  Bone-graft  Operation  for  Deformity 
of  the  Nose. — "Preparation  of  the  Patient:  Several  hours 
before  the  operation,  the  skin  over  the  nose,  face,  and  right 
side  of  the  chest  is  scrubbed  with  green  soap,  followed  by  alcohol. 
A  wet  dressing  of  bichloride,  1-1,000,  is  then  applied.  Just 
before  the  operation,  both  operative  fields  are  painted  with 
tincture  of  iodine,  and  the  eyebrows  are  covered  with  collodion. 
After  the  operation  begins,  no  solution  is  used  except  sterilized 
physiological  saline  solution  (salt,  9  gm. ;  sterile  water,  1.000  cc). 


Fig.  317. — Bone  with  periosteum  7  months  after  transplantation.      (William  Wesley 
Carter,  in   Medical  Record.) 

"Technique  of  Operation. — A  curvilinear  incision,  convexity 
downward,  is  made  between  the  eyebrows;  this  incision  extends 
down  to  the  periosteum  over  the  frontal  bone.  Lifting  the 
flap  up,  a  transverse  incision  is  made  through  the  periosteum 
and  into  the  bone  in  order  to  favor  osteogenesis  at  this  point. 
This  incision  corresponds  to  a  line  connecting  the  two  cornua  of 
the  semilunar  incision,  and  is  at  a  point  just  below  the  glabella. 
Above  this  incision,  the  periosteum  is  elevated  for  about  H  in. 


398  BONE-GRAFT    SURGERY 

With  the  sharp  elevator  devised  especially  for  this  purpose, 
the  skill  and  subcutaneous  tissue  is  then  elevated  over  the 
dorsum  of  the  nose,  and,  to  an  extent  corresponding  to  the 
degree  of  deformity,  over  the  sides  of  the  nose  and  in  some 
instances  over  the  cheeks.  If  any  of  the  nasal  bone  is  left,  its 
periosteum  should  be  elevated  so  that  the  bone  graft,  when  it  is 
introduced,  wiU  lie  in  close  contact  with  the  bone  and  its  torn 
periosteum. 


Fig.  318. — Bone  transplanted  v/ith  periosteum,  20  months  after  operation.  (Same 
case  as  Fig.  317.)  Note  growth  of  bone  and  development  of  canal  in  center.  (William 
Wesley  Carter,  in  Medical  Record.) 

"The  nose  having  been  prepared  for  the  reception  of  the 
graft,  the  next  step  is  to  remove  about  2  in.  of  the  ninth  rib, 
preserving  the  periosteum  on  the  outer  surface.  This  piece  of 
rib  is  then  split  in  its  transverse  diameter;  the  outer  half  is 
shaped  to  suit  the  deformity,  and  the  cancellous  tissue  is 
scraped  away,  leaving  only  a  thin  layer  of  compact  bone. 
Without  removing  the  blood  which  by  this  time  has  accumulated 
in  the  wound  in  the  nose  the  bone  graft  is  inserted  nearly  to  the 
tip  of  the  nose,  and  the  upper  end  is  carefully  placed  beneath 


SURGICAL  USES  OF  THE  BONE  GRAFT 


399 


the  periosteum  over  the  frontal  bone.  The  semihmar  flap  is 
then  brought  down  into  its  place,  and  the  wound  closed  with 
horsehair  sutures.  A  collodion  and  gauze  dressing  is  applied. 
The  sutures  may  be  removed  on  the  fifth  daj',  but  great  care 
must  be  exercised  not  to  disturb  in  any  way  by  manipulation 
the  blood-clot  which  has  formed  about  the  graft. 

"Bone  grafts,  either  covered  by  periosteum  or  bare,  but 
accidentally  separated  from  the  living  periosteum-covered  bone, 
appear   to   be  osteo-conductive  and   very  likely   osteogenetic. 


Fig.  319. — Before  and  after  operation.  Marked  depression  of  the  bridge  of  the  nose 
coming  on  since  disease  of  the  nose  and  curettage  4  years  before.  A  tibial  bone  graft 
was  inserted  by  the  author  with  an  excellent  cosmetic  result. 

In  one  case  now  under  observation,  the  transplant  is  consider- 
ably larger  than  when  it  was  introduced,  the  operation  having 
been  done  2  years  and  5  months  ago." 

The  author  has  obtained  equally  good  results  in  this  class  of 
cases  by  placing  the  graft  through  an  incision  in  the  tip  of  the 
nose.  The  bed  for  the  graft  is  prepared  by  thrusting  a  small 
scalpel  longitudinally  through  the  subcutaneous  tissue  of  the 
nose,  half  way  between  the  skin  of  the  bridge  and  the  mucous 
membrane  beneath  it,  until  the  glabella  of  the  frontal  bone  is 
reached.     The  periosteum  of  this  bone  is  incised  in  the  median 


400 


BONE-GRAFT   SURGERY 


line,  and  with  a  small  curette  under  the  j^uidance  of  external 
palpation  the  jieriosteuni  is  ])eeled  side-ways  and  the  bone 
beneath  scarified  for  a  fresh  contact  with  the  upper  end  of  the 
graft.  This  incision  leaves  a  scar  so  situated  that  it  is  hardly- 
noticeable. 


Fig.   320. — Rontgenogram  of  same  case  as  Fig.  319.      AB  is  bone  graft  in  place  and 
contacted  with  the  anterior  surface  of  nasal  bones  and  glabella. 


KANAVEL'S    OSTEOPLASTIC    CLOSURE    OF    THE    FACIAL    FORAMINA 

Kanavel  recommends  his  osteoplastic  operation  on  those 
cases  of  tic  douloureux  in  greatly  debilitated  patients  who  are  not 
good  surgical  risks  and  who  are  not  relieved  by  alcohol  injections, 


SURGICAL    USES    OF    THE    BONE    GRAFT  401 

or  in  those  patients  who  refuse  intracranial  procedures;  in  other 
words,  where  it  has  been  customary  to  avulse  tlie  nerve  or  fill 
the  foramina  with  foreign  bodies.  As  a  rule,  the  procedure  can 
be  done  under  local  anesthesia,  especially  by  trunk  injection. 

''In  the  operation  on  the  infraorbital  nerve,  the  incision  is 
made  in  the  line  of  the  skin  crease,  and  the  nerve  is  slowly 
twisted  from  its  trunk."  A  pedicle  trap-door  flap  of  periosteum 
about  the  foramen  is  turned  up.  The  canal  is  carefully  curetted, 
paying  special  attention  to  the  foramen.     A  small  bone  plug 


Fig.   321. — Graft  inserted  for  depressed  bridge  of  nose.      (Author's  case.) 

^i  in.  in  length  and  as  near  the  size  of  the  canal  as  possible 
is  removed  from  the  tibia,  a  piece  of  periosteum  the  size  of 
a  penny  being  left  attached  to  its  outer  end.  This  is  then 
wedged  into  the  canal  down  to  the  attached  periosteum. 
The  adjacent  periosteum  is  pushed  over  it,  and  the  skin 
closed  by  a  subcutaneous  stitch.  (See  Fig.  325.)  A  word  of 
warning  should  be  given  against  extending  the  infraorbital 
incision  too  far  toward  the  nose,  thus  endangering  the  lach- 
rymal sac." 

''In  the  inferior  dental  branch,  an  incision  is  made  under  the 

26 


402 


BONE-GKAFT    SURGERY 


angle  of  tlio  jaw  so  that  the  scar  is  out  of  sight.     The  skin  and 
miisch^s  are  next  detached  from  the  angle  upward.     A  crucial 


Fig.   322. — Method  of  exposing  and  renioviiiK  the  infraorlntal  nerve  by  torsion. 
(Kanavel,  in  Journal  of  the  American  Medical  Association.) 


Fig.  32.3. — Breaking  down  the  rim  of  the  infraorbital  canal.      (Kanavel,  in  Journal 
of  the  American  Medical  Association.) 

incision  (Fig.  326)  is  made  in  the  periosteum  at  the  angle  over 
the  area  of  the  nerve;  then  with  a  small  trephine  a  button  of  the 


SURGICAL  USES  OF  THS  BONE  GRAFT 


403 


outer  plate  of  bone  down  to  the  medulla  i.s  removed  (Fig.  327). 
The  nerve  is  found  and  twisted  out  of  its  canal.     The  canal  is 


Fig.  324. — Transplanted  bone  plug  in  position   with   periosteum  attached.      (Kanavel, 
in  Journal  of  the  American  Medical  Association.) 


Fig.  325. — Detached  periosteum  thrown  over  site  of  operation.  In  the  operation 
this  could  not  be  as  satisfactorily  done  as  would  appear  from  the  picture.  (Kanavel, 
in  Journal  of  the  American  Medical  Association.) 

then  curetted  thoroughly   and  broken   down.     The  button  of 
the  outer  plate  is  now  reinserted,  being  rotated  90  degrees  so 


404 


BONE-GKAFT   SURGERY 


Fig.  326. — Crucial  iiifi^iion  over  mn   im  Ih.iic  plug  over  infradental  canal.      (Kanavel, 
in  Journal  of  the  American  Medical  Association.) 


'^^:^f<!rrr' 


Pig.   327. — Torsion  and  removal  of  infradental   nerve.      (Kanavel,   in  Journal  of    the 
American  Medical  Association.) 


SURGICAL    USES    OF    THE    BONE    GRAFT 


405 


that  the  destroyed  canal  of  the  button  is  at  right  angles  to  the 
canal  in  the  bone,  and  it  is  driven  into  the  medulla  between  the 
two  tables  at  the  proximal  side  for  a  fraction  of  a  centimeter. 
The  periosteum  and  muscle-flaps  being  now  restored,  the  skin  is 


Fig.  328.- 


-Curetting  infradental  canal.      fKanavol,  in  Journal  of  the  American 
Medical  Association.) 


Fig.   329. — Replacing  boue  plug  at  right  angle  to  the  canal.      (Kanavel,  \w. Journal  of 
the  American  Medical  Association.) 

closed  by  a  subcutaneous  stitch.     The  patient  is  warned  not  to 
use  the  jaw  too  violently  for  some  weeks. 

Care  must  be  taken  not  to  injure  the  facial  nerve  when  re- 
tracting the  muscle  at  the  angle  of  the  jaw." 


INDEX  OF  NAMES 


axhausen,  28,  40 

Barth,  24,  26,  40 

Baum,  26 

Beebe,  122 

Berg,  56,  181,  185 

Berkeley,  122 

Bier,  26,  217 

Bissell,  196 

Bittner,  359 

Blake,  154,  156 

Bloxam,  395 

Bond,  35,  36,  37,  304,  361,  365 

Brackett,  254 

Buchmann,  387 

Buck,  196,  221,  275,  380 

Carr,  154 

Carter,  32,  37,  395,  396,  397,  398 

Charcot,  49,  144,  276,  296 

Cheyne,  393 

Chiari,  32 

Codivilla,  324,  359 

Corner,  344 

Cotton,  19,  221,  236 

Cotton  and  Loder,  18,  32 

Darling,  224 
Davis  and  Hunnicutt,  44 
de  Heyde,  39 
Deutschlander,  305 
Doyen,  52,  56 
Duhamel,  39 
Duniferline,  298 

Ely,  278 
Enderlen,  386 
Esmarch,  279 

FixxEY,  393,  394 
Frangenheim,  18 

Gallie,  324 
Galloway,  45 


Gant,  264 

Geist,  197 

Gigli,  52 

Goldthwait,  147,  300 

Graser,  300 

Grohe  and  Morfurgo,  17 

Groves,  40,  149,  155,  158,  159 

Hahn,  359 

Hardie,  395 

Hartley  and  Kenyon,  52,  55,  58,  63 

Havers,  39 

Hawley,  135,  175,  176,  177,  178,  179 

181,  184,  225,  227 

Hitzrot,  150,  156,  164,  214,  219,  225 

Hoffa,  244,  245,  250 

Hollis,  262 

Hunnicutt  and  Davis,  44 

Huntington,  35,  359 

Janeway,  17 

Jones  (Ellis  W.),  42,  43 

Jones  (Robert),  22,  23,  150,  365,  366 

Kaxavel,  49,  400,  402,  403,  404,  405 

Katzenstein,  381,  382 

Kausch,  24,  25 

Keller,  110 

Kenyon  and  Hartley,  52,  55,  58,  63 

Killian,  135 

Kirmisson,  370,  371 

Koch,  64,  297,  299,  335 

Krogius,  297 

Kiimmell,  144 

Kiittner,  22,  383,  386,  387 

Laewen,  27 

Lambotte,  56,  179,  184,  213 
Lane,  137,  149,  151,  153,  154,  165, 
167,  168,  170,  171,  175,  180,  181, 

182,  193,  194,  195,  199,  202,  203, 
209,  210,  211,  212,  213,  216,  219 

Lange,  72 
Lasse,  390 


407 


408 


INDEX  OF  NAMES 


Lathrop,  160 

Lexer,  20,  22,  2G,  50,  333,  334,  383, 

384,  385,  386,  388,  390 
Loder  and  Cotton,  IS,  32 
Lowman,  56,  180,  185 
Luflwrrow,  348 
Lylc,  216,  217,  263 

Macewen,  18,  36,  39,  88,  126,  199 

Martel,  62,  391 

Martin,  153,  154 

Mayer,  18 

Mtiilcr,  359 

McWilliams,  18,  19,  39 

INIcrrem,  18 

Morfurgo  and  Grohe,  17 

Neugebauer,  135 
Nichols,  35,  359 

Ollier,  18,  40,  53,  359 
Osgood,  279 

Palmer,  143 
Parkhill,  213 
Peck,  98 
Perthes,  389 
Phems,  310 
Phelpister,  18,  208 
Phimmer,  201 
Pott,  64 

Reclus,  242 

Roberts,  50,  153,  265,  268 
Rogers,  231,  277 
Ropke,  391 


Roux,  32,  46 
Rovsing,  373,  386 
Ryerson,  140 

Saihne,  395 

Sawtello,  214 

Schewaiidin,  334 

S(-hul5!('-I}orffc,  38,  306 

Scudder,  221 

Silver,  135 

Soulc,  112,  115,  117,  118,  119,  121, 

327,  331,  334 
Stillc,  215 
Stimson,  215,  220 
Stohr,  30 
Stone,  35,  359,  360,  361,  362,  363, 

364 

Tenney,  298 
Thomas,  144,  165,  310 
Troja,  39 
Tschirch,  369 
Turns,  395 

Van  Horn,  214 
Vredena,  395 
Vulpius,  359 

Walker,  221 

Walther,  IS,  373 

Whitlock,  297,  298,  299 

Whitman,  178,  221,  224,  230,  333 

Wille,  344 

Wolff,  29,  33,  34,  35,  36,  37,  38,  168, 

189,  211,  288,  353,  365,  386 
Wrede,  335 


INDEX 


Absence  of  fibula,  3S3 

congenital,  Albee's  technique  in, 
343 
of  tibia,  359 

Albee's  technique  in,  367 
Huntington's  technique  in,  3.59 
Stone's  technique  in,  359 
Albee's  arthrodesis  operation  of  hip, 
252 
bone-wedge    graft    operation    for 
acquired    dislocation    of 
hip,   245 
for    congenital    dislocation 
of  hip,  245 
electric  motor  operating  outfit,  52 
cutting  instruments,  56 
description,  55 
dowel      instrument       or 

lathe,  57 
guard  with  spray,  58 
Hartley-Kenyon  method 

of  sterilization,  58 
manner  of  holding  saw,  61 
Martel's  attachment,  62 
method    of    putting    to- 
gether, 59 
single  saw,  56 
small  saw,  58 
technique  of  using,  63 
twin  saw,  57 
twist  drills,  58 
inlay  method,  31 
osteotome,  77 

technique  in  absence  of  tibia,  367 
in  acquired  clubfoot,  321 

Soule's  modification,  327 
in  ankylosis  of  hip,  252 
in  Charcot's  knee,  296 
in  clubfoot,  308 

in  congenital  absence  of  fibula, 
343 
dislocation  of  patella,  301 
in  flat-foot,  331 

in   habitual   dislocation   of  pa- 
tella, 301 


All)ee's  technique  in  parah'tic  scoli- 
osis, 129 
in  Pott's  disease,  73,  76,  78 
advantages,  102 
contra-indication  to,  104 
convalescence  after,  99 
dressings  after,  93 
experimental  application  of 
methodtospineofdog,107 
external  support   to   spine 

after,  102 
fixation  of  graft  in  position. 

85 
indications  for,  104 
method  of  fixation  in  bed 

after,  99 
post-operative     treatment, 
general,  99 
immediate,  96 
prognosis  after,  104 
removal  of  graft,  81 
summary,  102,  124 
in  spina  bifida,  141 
in  spondjdolisthesis,  137 
in   stiffening   knee   in   infantile 

paralysis,  293 
in     tuberculosis     of     sacroiliac 

joint,  145 
of  bone-graft  peg  in  fracture  of 

OS  calcis,  236 
of  inlaj'  bone  graft  in  fracture  of 
patella,  232 
in  fractures,  149,  181 
with  wedge  cross-sec- 
tion, 185 
in  tuberculosis  of  knee- 
joint,  281 
Ankle-joint,  arthrodesis  of,  333 

astragalus    used    as    transplant 

for,  335 
Lexer's  technique,  333 
Wrede's,  335 
tuberculosis  of,  bone  graft  in,  338 
tuberculous  osteitis  of,  bone  graft 
in,  338 


409 


410 


INDEX 


Ankylo.siiiK       liii)-j()int,       oix'iative 
metliods,  242 
knoo-joint    in    infant ilo    paralysis, 
2')(l 
Albee's  tet'hnique,  293 
Hibbs'  technique,  298 
Ankylosis  of  liii),   Alhoo's  operation 

for.  252 
Artliritis  deformans  of  hip.   Albee's 
operation,  252 
operative  treatment,  24!) 
Arthrodesis  of  ankle-joint,  '.V.V.\ 

astragalus    used    as    transplant 

for,  335 
Lexer's  teehnitiue,  333 
Wrede's,  335 
of    astragalo-scaphoid     joint     for 

flat-foot,  330 
of   knee-joint  in  infantile  paraly- 
sis, 290 
Albee's  technique,  293 
Hibbs'  technique,  293 
operation    of    hip,    Albee's    tech- 
nique, 252 
Asepsis,  29 

Astragalo-scaphoid     joint,     arthro- 
desis of,  for  flat-foot,  330 
Astragalus  graft  for  loss  of  femoral 
head  and  neck,   Albee's  modi- 
fication of  Roberts'   technique, 
265 
used  as  transplant  to  arthrodese 
ankle,  335 
Autogenous  bone  graft,  23,  27 
in  fracture  of  patella,  230 
in  osteitis   filn-osa  cystica  of 
upper  end  of  femur,  268 

Bacteria-resisting    properties    of 

bone  graft,  44 
Baking  in  fractures,  215 
Blood,  danger  of,  20 
Blood-vessels  of  bone,  30 
Boiled  bone  as  substitute  for  bone 

graft,  24,  26 
Bond's  theory,  37 
Bone,  blood-vessels  of,  30 

boiled  as  substitute  for  bone  graft, 
24,  26 

contact,  31 

defect  of  skull,  bone  graft  for,  391 


Bone  graft,  autogenous,  23,  27 

in  fracture  of  patella,  230 

in  osteitis  fibrosa  cystica  of 
upper  end  of  femur,  268 
bacteria-resisting  jjiopci'ties  of, 

44 
contra-indications,  51 
factors  controlling  growth  and 

development,  35 
failures  in  use  of,  20 
fixation  in   position,    in    Pott's 

disease,  85 
for  radius,  373 
from  filnda  to  replace  upper  end 

of  femur,  2()S 
from  tibia  to  replace  upper  end 

of  femur,  268 
fundamental    principles    under- 
lying use  of,  17 

rules  for,  28 
general  indications,  48-50 
heteroplastic,  21 

difficulty  with,  22 
histological  role  of,  18 
homoplastic,  20 

fibrous  encapsulation  in,  20 
in  absence  of  fibula,  383 

of  tibia,  359 
in  acquired  clubfoot,  319 
in  angular  curvature  of  spine,  64 
in  caries  of  spine,  64 
in  Charcot's  disease,  144 
in  clubfoot,  308 

advantages  of,  319 
in  congenital  absence  of  fibula, 

Albee's  technique,  343 
in  defects  of  nose,  395 

Carter's  technique,  397 

of  skull,  391 
in  diseases  and  deformities  of 

foot  and  leg,  308 
in  disintegration  of  tarsal  bone, 

354' 
in  dislocation  fractures,  387 

of  sacroiliac  joint,  147 
in  fracture  of  cervical  spine,  144 

of  spine,  143 
in  hump-back,  64 
in  hydrorrhachis,  140 
in  Kiimmell's  disease,  144 
in  kyphosis,  64 


INDEX 


411 


Bone  graft  in  lateral  curvature  of 
spine,  126 

in  lesions  of  spine,  64 
in  neuropathic  spine,  144 
in    osteitis    fibrosa    cj'stica    of 

humerus,  378 
in  paralytic  equino  varus,  319 
scoliosis,  126 

mechanics  of  correction  by, 
128 
in  Pott's  disease,  64 
in  relaxation  of  sacroiliac  joint, 

147 
in  restoration  of  l)ones  of  foot, 

354 
in  sarcoma  of  bone,  306 

of  radius,  373 
in  spina  l)ifida,  140 

ventosa,  376 
in  spondylitis,  64 
in  spondylolisthesis,  134 
in  tarsal  disease,  338 
in  traumatic  spondylitis.  144 
in  tuberculosis  of  bone,  343 
of  sacroiliac  joint,  144 
of  vertebra?,  64 
in  tuberculous  osteitis  of  ankle, 

338 
inlay,  in  fracture  of  both  bones 
of  forearm,  218 
of  clavicle,  216 
of  jaw,  239 
of  olecranon,  218 
of  patella,  232 
of  ulna  and  radius,  218 
in  fractures,  149 

after-treatment,  216 
Albee's  technique,  149,  181 
with  wedge  cross-sec- 
tion, 185 
armamentarium  for,  179 
technique,  179 
in  pseudarthrosis,  192 
after-treatment,  216 
in  stiffening  knee-joint  in  in- 
fantile paralysis,  290 
in     tuberculous    knee-joints, 
276 
Albee's  technique,  281 
osteitis  of   knee   in    adult, 
277 


Bone  graft  inlay,  in  tuberculous  os- 
teitis of  knee  in  childhood,  276 
intrameduUarj-,  26 
Kausch's  table  of  value  of  differ- 
ent materials  for,  25 
miscellaneous  surgical  uses,  357 
of  small  bones,  383 
preservation  of,  47 
removal  of ,  for  use  in  Pott's  dis- 
ease, 81 
growth,    continuous,   grafting    of 

epiphysis  to  stimulate,  304 
hypertrophy  of,  38 
infection  of,  41 

sarcoma  of,  bone  graft  in,  306 
tarsal,     disintegration     of,     bone 

graft  in,  354 
tuberculosis  of,  bone  graft  in,  343 
Bone-graft  peg  in  fracture  of  neck 
of  femur,  222 
Albee's  technique,  225 
indications  for,  224 
of  OS  calcis,  235 

Albee's  technique,  236 
fixation  dressing  after,  238 
in  fractures,  212 
wedge  in  acquired  dislocation  of 
hip,  242 
Albee's  technique,  245 
in  congenital  dislocation  of  hip, 

Albee's  technique,  245 
in  paralytic  dislocation  of  hip, 

242 
in    relapsing    congenital    dislo- 
cation of  hip,  242 
Bone-marrow,      grafting      of,      into 

spleen,  33 
Bones   of   foot,  restoration  of  bone 
graft  in,  354 
small,  transplantation  of,  383 
Braces  in  Pott's  disease,  69 
Brackett's    method    of    lateral    ap- 
proach to  hip-joint,  254 
British  Medical  Association,  council 
of,    report    of,    on    treatment    of 
fractures,  158 
Buchmann's     technique     in     bony 
ankylosis  of  elbow-joint,  387 

Cambium  layer  of  periosteum,  39 
Caries  of  spine,  64 


412 


INDEX 


Carter's  tccliniciiic  df  hone  fii'aft 
operation  I'ordcl'onnity  of  nose,  397 

Cellular  life,  17 

dui'Mt  ion  of,   1  7 

Ccrvieal  .s])ine,  fracture  of,  144 

Charcot's  disease,  1 44 

Albee's  teehniejue  for,  296 

Clamp,  Parkhill,  in  fractures,  213 

Clavicle,    fracture    of,     inlay    hone 
graft  in,  21(1 
ril)  graft  for,  3(39 

Clubfoot,  30S 
acquired,  319 

Albee's  technique,  321 

Soule's  modification,  327 
advantages  of  bone  graft  in,  319 
Albee's  technique,  308 
paralytic,  319 
sling,  317 

Contra-indications  to  bone  grafts,  51 

Convalescence  after  Albee's  tech- 
nique in  Pott's  disease,  99 

Council  of  British  Medical  Associa- 
tion, report  of,  on  treatment  of 
fractures,  158 

Curvature,  angular,  of  spine,  64 
lateral,  of  spine,  126 

Dangle  hip,  operative  treatment,  249 
Deformities  of  foot  and  leg,  308 
of  nose,  393,  395 

Carter's  technique,  397 
Dislocation,   congenital,   of  patella, 
Albee's  technique,  301 
fracture,  bone  graft  in,  387 
habitual,  of  patella,  296 
Albee's  technique,  301 
Dumferline's   technique,    298 
Goldthwait's  technique,  300 
Graser's  technique,  300 
Krogius'  technique,  297 
Murphy's  technique,  300 
Whitlock's  technique,  299 
of    hip,    acquired,    Albee's    bone- 
wedge     graft     operation 
for,  245 
bone-graft  wedge  in,  242 
congenital,  Albee's  bone-wedge 
graft  operation  for,  245 
relapsing,    bone-graft    wedge 
in,  242 


Dislocation    of    liij),  paralytic,  bone- 
graft  wedge  in,  242 
of  sacroiliac  .joint,  147 

(roldthwait's  symptom,  147 
Dowel  instrument,  57 
Dressing  after  Albee's  techriiciue  in 
paralytic  scoliosis,  131 
in  Pott's  disease,  93 
fixation,   after  bone-graft  peg  in 
fracture  of  os  calcis,  238 
for  fractures,  214 
Drills,  twist,  58 

Dumferline's  technique  for  habitual 
dislocation  of  patella,  298 

Electric  motor  operating  outfit, 
52.  See  also  Albee's  electric  motor 
operating  outfit. 

Epiphysis,  grafting  of,  to  stimulate 
continuous  bone  growth,  304 

Equino  varus,  paralytic,  319 

Facial  foramina,   Kanavel's  osteo- 
plastic closure  of,  400 
neuralgia,     Kanavel's     operation 
for,  400 
Femur,   head  and   neck,   astragalus 
graft  for  loss  of,  Albee's  modi- 
fication of  Roberts'  tecluiique, 
265 
neck  of,  fracture,  220 

bone-graft  peg  in,  222 

Albee's  technique,  225 
indications  for,  224 
treatment  of,  221 
upper  end,  osteitis  fibrosa  cystica 
of,  autogenous  bone  graft  in,  268 
Fibrous     encapsulation     in     homo- 

plasty,  20 
Fibula,  absence  of,  bone  graft  in,  383 
bone  graft  from,  to  replace  upper 

end  of  femur,  268 
congenital     absence     of,     Albee's 
technique  in,  343 
Finger  as  transplant,  rhinoplasty  by 

means  of,  393 
Finney's   rhinoplasty   by   means   of 

finger,  393 
Fixation    dressing    after    bone-graft 
peg  in  fracture  of   os  calcis, 
238 


INDEX 


413 


Fixation  dressing  for  fractures,  214 
of  fractures  by  absorbable  or  non- 
absorbable ligature  material, 
213 
by  bone-graft  dowel  pegs,  212 
Flat-foot,  Albee's  technique,  331 
arthrodesis  of  astragalo-scaphoid 
joint  for,  319 
Flexible  probe,  80 

Foot  and  leg,  diseases  and  deformi- 
ties, bone  graft  in,  308 
bones    of,    restoration    of,    bone 
graft  in,  354 
Foramina,   facial,    Kanavel's   osteo- 
plastic closure  of,  400 
Forearm,  both  bones,  fracture  of,  in- 
lay bone  graft  in,  218 
Fracture  of  both  bones  of  forearm, 
inlay  bone  graft  in,  218 
of  cervical  spine,  144 
of  clavicle,  inlay  bone  graft  in,  216 
of  jaw,  inlay  bone  graft  in,  239 
of  neck  of  femur,  220 

bone-graft  peg  in,  222 

Albee's  technique,  225 
indications  for,  224 
treatment,  221 
of  olecranon,  inlay  bone  graft  in, 

218 
of  OS  calcis,  bone-graft  peg  in,  235 
Albee's  technique,  236 
fixation    dressing    after, 
238 
of  patella,  Albee's  technique,  232 

autogenous  bone  graft  for,  230 
of   radius   and   ulna,    inlay   bone 

graft  in,  218 
of  spine,  143 

of  ulna   and   radius,    inlay   bone 
graft  in,  218 
Fractures,  Albee's  technique  of  inlay 
bone  graft  in,  149,  181 
with  wedge  cross-sec- 
tion, 185 
baking  in,  215 

dislocation,  bone  graft  in,  387 
fixation  of,  by  absorbable  or  non- 
absorbable ligature  material, 
213 
by  bone-graft  dowel  pegs  in,  212 
dressing  for,  214 


Fractures,  fresh,  after-treatment  of, 
215 
operative  treatment,  171 

preparation  of  patient,  177 
time  for,  171 
inlay  bone  graft  in,  149 

after-treatment,  216 
Albee's  technique,  149,  181 
with  wedge  cross-sec- 
tion, 185 
armamentarium  for,  179 
technique  of,  179 
kangaroo  tendon  for,  214 
Lane's  plates  in,  153,  165 
liniments  in,  216 
operative  treatment,    149 

contra-indications  to,  214 
indications  for,  156 
osteoblasts  in  repair  of,  35 
Parkhill  clamp  in,  213 
physiological  repair  of,  35 
plaster-of-Paris  splint  in,  214 
pseudarthrosis   after,    inlay   bone 
graft  for,  192 
after-treatment,  216 
report  of  council  of  British  Medi- 
cal Association  on  treatment  of, 
158 
wiring  of,  213 
Freezing  for  preservation  of  bone- 
graft  material,  47 
Functional  irritation,   Roux's  post- 
operative, 32 
Fundamental  rules  for  bone  grafts, 
28 

Goldthwait's    symptom    in    dislo- 
cation of  sacroiliac  joint,  147 
technique  for  habitual  dislocation 
of  patella,  300 
Graft,  astragalus,  for  loss  of  femoral 
head  and  neck,   Albee's  modi- 
fication of  Roberts'  technique, 
265 
bone.     See  Bone  graft. 
of  epiphysis  to  stimulate  continu- 
ous bone  growth,  304 
rib,  for  clavicle,  369 
Graser's  technique  for  habitual  dis- 
location of  patella,  300 
Guard  with  spray,  58 


414 


INDEX 


Habitual  dislocation  of  patella,  29G 
Albee's  tcchniqvio,  301 
Duniferliiic's  technique,  298 
Goldtluvait's  technique,  300 
Grascr's  technique,  300 
Krosius'  technique,  297 
Murphy's  technique,  300 
Whitlock's  technique,  299 
Hapmatoma,  30 

Half-joint  transplantation,  38G 
Hartley-Kenyon   method   of   sterili- 
zation of  electric  motor  operating 
outfit,  58 
Hawley  table,  175,  176,  177,  178 

Silver's  attachment  to,  135 
Hematoma,  30 
Heteroplastic  grafts,  21 
difficulty  with,  22 
Hibbs'  operation  for  stiffening  knee- 
joint  in  infantile  paralysis,  292 
Hip-joint,  Albee's  arthrodesis  opera- 
tion of,  252 
ankylosing,  operative  methods,  242 
arthritis    deformans    of,     Albee's 
operation  for,  252 
operative  treatment,  249 
dangle,  operative  treatment,  249 
disease,  tuberculous,  adult,  opera- 
tive treatment,  249 
dislocation   of,    acquired,    Albee's 
bone-wedge  graft  operation 
for,  245 
bone-graft  wedge  in,  242 
congenital,  Albee's  bone-wedge 
graft  operation  for,  245 
relapsing,    bone-graft    wedge 
in,  242 
paralytic,  bone-graft  wedge  in, 
242 
osteoarthritis    of,    Albee's    opera- 
tion for,  252 
operative  treatment,  249 
paralytic,  operative  treatment,  249 
remodelling  of,  operative  methods 

for,  242 
traumatic,  operative  treatment, 249 
tuberculosis   of,    adult,    operative 
treatment,  249 
Homoplastic  grafts,  20 
Humerus,  osteitis  fibrosa  cystica  of, 
378 


nuiii])-l);ick,  til 

Huntington's  technique  in  absence 

of  tibia,  359 
Hydrorrhachis,  140 
nyi)ertrophy  of  bone,  38 

Indications,      general,      for     bone 

grafts,  48-50 
Infantile  paralysis,  Hibbs'  operation 
I'oi' stiffening  knee-joint  in,  292 
inlay   bone   graft   for  stiffening 

knee  in,  290 
stiffening  knee  in,  Albee's  tech- 
nique, 293 
Infection  of  bone,  41 
Inlay  bone  graft,  31 

in  fracture  of  clavicle,  216 
of  jaw,  239 
of  olecranon,  218 
in  fractures,  149 

after-treatment,  216 
Albee's  technique,  149,  181 
with  wedge  cross-sec- 
tion, 185 
armamentarium  for,  179 
of    both    bones     of    fore- 
arm, 218 
of  patella,  232 
of  ulna  and  radius,  218 
technique,  179 
in  pseudarthrosis,  192 
after-treatment,  216 
in  stiffening  knee-joint  in  in- 
fantile paralysis,  290 
in  tuberculous  knee-joints,  276 
Albee's  technique,  281 
osteitis  of  knee  in  adults, 
277 
in  childhood,  276 
Intramedullary  graft,  26 
Irritation,  functional,   Roux's  post- 
operative, 32 
Ivory  as  substitute  for  bone  grafts, 
26 

Jaw,  fracture  of,  inlay  bone  graft  in, 

239 
Joints,  transplantation  of,  305,  384 

Kanavel's    osteoplastic    closure    of 
facial  foramina,  400 


INDEX 


415 


Kangaroo  tendon  for  fractures,  214 
Kausch's  tal)le  of  value  of  different 
materials  for  bone  transplantation, 
25 
Knee-joint,  Charcot's,  Albee's  tech- 
nique, 296 
stiffening  of,  in  infantile  paralysis, 
290 
Albee's  technique,  293 
Hibbs'  technique,  292 
transplantation  of,  305 
tuberculosis    of,  inlay  bone    graft 
for,  276 
Albee's  technique,  2S1 
tuberculous  osteitis  of,   in  adult, 
inlay  bone  graft  for,  277 
in     childhood,     inlay     bone 
graft  for,  276 
Krogius'  technique  for  habitual  dis- 
location of  patella,  297 
Kiimmeirs  disease,  144 
Kj'phosis,  64 

Lane's  plates  in  fractures,  153,  165 

Lange's  treatment  of  Pott's  disease, 
72 

Lathe,  57 

Law,  Wolff's,  29,  33,  35 

Layer,  cambium,  of  periosteum,  39 

Leg  and  foot,  diseases  and  deformi- 
ties, 308 

Lexer's  technique  for  arthrodesis  of 
ankle,  333 

Ligature  material,  absorliable  or  non- 
absorbable, fixation  of  fractures 
by,  213 

Liniments  in  fractures,  216 

Martel's  attachment  to  Albee's 
electrical  surgical  outfit,  62 

Murphy's  technique  for  habitual  dis- 
location of  patella,  300 

Neuralgia,  facial,  Kanavel's  opera- 
tion for,  400 
Neuropathic  spine,  144 
Nose,  defects  of,  393,  395 
Carter's  technique,  397 

Olecranon,  fracture  of,  inlay  bone 
graft  in,  218 


Operative    treatment    of    fractures, 
149 
contra-indications,  214 
indications,  156 
inlay  bone  graft  in,  149 
of  fresh  fractures,  171 

preparation  of  patient,  177 
time  for,  171 
Os  calcis,  fracture  of,  bone-graft  peg 
in,  235 
Albee's  technique,  236 
fixation    dressing    after, 
238 
Osteitis  fibrosa  cystica  of  humerus, 
378 
of  upper  end  of  femur,  268 
tuberculous,  of  ankle,  bone  graft 
in,  338 
of   knee,    in   adult,    inlay   bone 
graft  for,  277 
in  childhood,  inlay  bone  graft 
for,  276 
Osteoarthritis  of  hip,  Albee's  opera- 
tion for,  252 
operative  treatment,  249 
Osteoblasts    in    repair  of  fractures, 

35 
Osteogenesis,  relative,  199 
Osteoplastic    closure,    Kanavel's,  of 

facial  foramina,  400 
Osteotome,  Albee's,  77 

Paralysis,  infantile,  Hibbs'  opera- 
tion for  stiffening  knee-joint 
in,  292 
inlay  bone  graft  for  stiffening 

knee  in,  290 
stiffening      knee      in,      Albee's 
technique,  293 
Paralytic  clubfoot,  319 

dislocation     of     hip,     bone-graft 

wedge  in,  242 
equine  varus,  319 
hip,  operative  treatment,  249 
scoliosis,  126 

Albee's  technique,  129 

post-operative     treatment, 
131 
mechanics  of  correction  by  bone 
graft,  128 
Parkhill  clamp  in  fractures,  213 


416 


INDEX 


Patell;i,    coiifioiiital    dislocation     of, 
Albee's  technique,  301 
fracture  of,  Albee's  technique  in, 
232 
autofienous  l)one  j^iaft  for,  230 
lialiit\ial  (lishjcation  of,  296 
Albee's  technique,  301 
Duniferline's  technique,  298 
Goldthwait's  technique,  300 
Graser's  technique,  300 
Krogius'  technique,  297 
jNIurphy's  technique,  300 
\Miitl()ck's  technique,  299 
Peg,      bone-graft.     Sec      Bone-graft 

peg- 

Periosteum,  caniljiuni  layer  of,  39 
role  of,  38 

transplanted,  viability  of,  17 
Plaster-of-Paris  jackets  in  Pott's  dis- 
ease, 69 
splint  in  fractures,  214 
Post-operative       treatment       after 
Albee's    technique    in    para- 
lytic scoliosis,  131 
general,  after  Albee's  technique 

in  Pott's  disease,  99 
immediate,  after  Albee's  tech- 
nique in  Pott's  disease,  96 
Pott's  disease,  64 

Albee's  technique,  73,  76,  78 
advantages,  102 
contra-indication  to,  104 
convalescence  after,  99 
dressings  after,  93 
experimental  application  of 
method  to  spines  of  dogs, 
107 
external   support  to   spine 

after,  102 
fixation   of    grafts  in   posi- 
tion, 85 
indications  for,  104 
method  of  fixation  in  bed 

after,  99 
post-operative     treatment, 
general,  99 
immediate,  96 
prognosis  after,  104 
removal  of  graft,  81 
summary,  102,  124 
braces  in,  69 


Pott's  disease,  duralion,  lOo 
Lange's  treatment,  72 
location,  105 

plaster-of-Paris  jackets  in,  (')9 
recumbency  in,  69 
Preparation  of  patient  for  operative 

treatment  of  fresh  fractures,  177 
Preservation  of  bone  graft,  47 
Probe,  flexible,  80 

Pseudarthrosis,  inlay  boiu;  graft   in, 
192 
after-treatment,  216 

Radius  and  ulna,  fracture  of,  inlay 
bone  graft  in,  218 
bone  graft  for,  373 
sarcoma  of,  bone  graft  in,  373 

Recumbency  in  Pott's  disease,  69 

Relaxation  of  sacroiliac  joint,  147 

Remodelling  hip-joint,  operative 
methods,  242 

Report  of  Council  of  British  Medical 
Association  on  results  of  treatment 
of  fractures,  158 

Rhinoplasty  by  means  of  finger  as 
transplant,  393 

Rib  graft  for  clavicle,  369 

Roberts'  technique  of  astragalus 
graft  for  loss  of  femoral  head  and 
neck,  Albee's  modification,  265 

Roux's  post-operative  functional  ir- 
ritation, 32 

Sacroiliac  joint,  dislocation  of,  147 
Goldthwait's  symptom,  147 
relaxation  of,  147 
tuberculosis  of,  144 
Albee's  technique,  145 
Salt    solution    for    preservation    of 

bone-graft  material,  47 
Sarcoma  of  bone,  306 

of  radius,  373 
Saw,  single,  56 
small,  58 
twin,  57 
Scoliosis,  paralytic,  126 

Albee's  technique,  129 

post-operative     treatment, 
131 
mechanics  of  correction  by  bone 
graft,  128 


INDEX 


417 


Silver's  attachment  to  Hawley  table, 

135 
Skull,  defect  of,  391 
Sling,  clubfoot,  317 
Soil,  \yound,  19 

Soule's  modification  of  .lll^ee's  tech- 
nique for  acquired  clubfoot,  327 
Spina  bifida,  140 

Albee's  technique,  141 

ventosa,  376 
Spine,  angular  curvature  of.  64 

caries  of,  64 

cervical,  fracture  of.  144 

curvature  of,  lateral,  126 

external  support  to,  after  Albee's 
technique     in     Pott's     disease, 
102 

fracture  of,  143 

lesions  of,  64 

neuropathic,  144 

tuberculosis  of,  64 
Spleen,  grafting  of  bone-marrow  into, 

33 
Splint,  plaster-of-Paris,  in  fractures, 

214 
Spondj-litis,  64 

traumatic,  144 
Spondylolistliesis,  134 

Albee's  technique,  137 
Sterilization   of   electric    motor   op- 
erating    outfit,     Hartley-Kenyon 

method,  58 
Stiffening  of  knee-joint  in  infantile 
paralysis,  290 
Albee's  technique,  293 
Hibbs'  technique,  293 
Stone's    technique    in    absence    of 

tibia,  359 
Syphilis,  51 

Table,  Hawley,  175,  176,  177,  178 

Silver's  attachment  to,  135 
Talipes  equino  varus,  319 
Tarsal  bone,  disintegration  of,  354 

disease,  338 
Tibia,  absence  of,  359 

Albee's  technique  in,  367 
Huntington's       technique       in, 
359 

27 


Tibia,  absence  of,  Stone's  technique 
in,  359 
bone  graft  from,  to  replace  upper 
end  of  femur,  268 
Tic    douloureux,    Kanavel's    opera- 
tion for,  400 
Transplantation,  half-joint,  386 
of  joints,  305,  384 
of  knee-joint,  305 
of  periosteum,  viability  of,  17 
of  small  bones,  383 
whole-joint,  386 
Trauma,  29 

Traumatic  hip,  operative  treatment, 
249 
spondylitis,  144 
Tuberculosis  of  ankle-joint,  338 
of  bone,  343 
of  hip,  adult,  operative  treatment, 

249 
of    knee-joint,    inlay    bone    graft 
for,  276 
Albee's  technique,  281 
of  sacroiliac  joint,  144 

Albee's  technique,  145 
of  vertebrse,  64 
Tuberculous  osteitis  of   ankle,    338 
of    knee    in    adult,    inlay    bone 
graft  for,  277 
in  childhood,  inlay  bone  graft 
for,  276 
Twin  saw,  57 
Twist  drills,  58 

Ulna  and  radius,  fracture  of,  inlay 
bone  graft  in,  218 

Vaseline  for  preservation  of  bone- 
graft  material,  47 
Vertebra^,  tuberculosis  of,  64 

Whitlock's  techniciue  for  habitual 
dislocation  of  patella,  299 

Whole-joint  transplantation,  386 

Wiring  of  fractures,  213 

Wolff's  law,  29,  33,  35 

Wound  soil,  19 

Wrede's  arthrodesis  of  ankle-joint, 
335 


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INCLUDING  VACCINES  AND  SERUMS 

Dr.  Ward's  work  gives  you  the  exact  technic  for  obtaining  the  blood  for  ex- 
amination, the  making  of  smears,  the  blood-count,  finding  coagulation  time,  etc. 
Then  it  takes  up  each  disease,  giving  you  the  synonyms,  definition,  nature,  gen- 
eral pathology,  etiology,  bearings  of  age  and  sex,  the  onset,  symptomatology  (dis- 
cussing each  symptom  in  detail),  course  of  the  disease,  clinical  varieties,  compli- 
cations, diagnosis,  and  treatment  (drug,  diet,  rest,  vaccines  and  serums,  etc.). 


Faught*s  Blood-Pressure 

Blood  =  Pressure  from  the  Clinical  Standpoint.  By  Francis  A. 
Faught,  M.  D.,  Instructor  in  Medicine,  Medico-Chirurgical  College  of 
Philadelphia.     Octavo  of  281  pages,  illustrated.     Cloth,  ^$3.00  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Faught' s  book  is  designed  for  practical  help  at  the  bedside.  Besides  the 
actual  technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The  practical 
application  of  sphygmomanometric  findings  within  recent  years  make  it  imperative 
for  every  medical  man  to  have  close  at  hand  an  up-to-date  work  on  this  subject. 


Smith's  What  to  Eat  and  Why 

What  to  Eat  and  Why.     By    G.    Carroll   Smith,  M.D,,  Boston. 

l2mo  of  377  pages.     Cloth,  $2.50  net. 

JUST  OUT— NEW   (2d)  EDITION 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be 
dieted — you  will  be  able  to  prescribe  the  suitable  diet  yourself  just  as  you  do 
other  forms  of  therapy.  Dr.  Smith  gives  the  "why"  of  each  statement  he 
makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book,  which 
makes  you  feel  that  Dr.  Smith  knows. 

Pennsylvania  Medical  Journal 

"All  through  this  book  Dr.  Smith  has  added  to  his  dietetic  hints  a  great  many  valuable  ones 
of  a  general  nature,  which  will  appeal  to  the  general  practitioner." 


SAUNDERS'   BOOKS    ON 


Kolmer*s  Specific  Therapy 

Infection,  Immunity,  and  Specific  Therapy.  By  John  A.  Kolmer, 
M.  D.,  Dr.  p.  II.,  In.structor  in  Plxperimcntal  Pathology,  University  of 
Pennsylvania.  Octavo  of  900  pages,  with  143  original  illustrations,  43 
in  colors,  drawn  by  Erwin  Y.  Faber.     Cloth,  ^6.00  net ;  Half  Morocco, 

$7.50  net. 

ORIGINAL  ILLUSTRATIONS 

Dr.  Kolmer' s  book  gives  you  a  full  account  of  infection  and  immunity,  and 
the  application  of  this  knoivledge  in  the  specific  diagnosis,  prevention,  and  treat- 
ment of  disease.  The  section  devoted  to  iiiiDiunologic  techttic  gives  you  every  de- 
tail, from  the  care  of  the  centrifuge  and  making  a  simple  pipet  to  the  actual  pro- 
duction of  serums  and  vaccines.  Under  specific  thet-apy  you  get  methods  of 
making  autogenous  vaccines  and  their  actual  2tse  in  diagnosis  and  treatment.  The 
directions  for  injecting  vaccines,  serums,  salvarsan,  etc. — with  the  exact  dosage — 
are  here  given  so  clearly  that  you  will  be  able  to  use  these  means  of  treatment  in 
your  daily  practice.  You  also  get  full  directions  for  making  the  clinical  diagnostic 
reactions — the  various  tuberculin  tests,  luetin,  mallein,  and  similar  reactions,  all  illus- 
trated with  colored  plates.      The  final  section  is  devoted  to  laboratory  experimeiits. 


Anders  ^  Boston's  Medical  Diagnosis 


A  Text=Book  of  Medical  Diagnosis.  By  James  M.  Anders,  M.  D., 
Ph.  D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and 
of  Chnical  Medicine,  and  L.  Napoleon  Boston,  M.  D.,  Professor  of 
Physical  Diagnosis,  Medico-Chirurgical  College,  Philadelphia.  Octavo 
of  1248  pages,  with  466  illustrations,  a  number  in  colors.  Cloth,  $6.00 
net;  Half  Morocco,  ^J.^o  net. 

NEW  (2d)  EDITION 

This  new  edition  is  designed  expressly  for  the  general  practitioner.  The 
methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 
diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory'. 

The  Medical  Record 

"  The  association  in  its  avtthorship  of  a  celebrated  clinician  and  a  well-known  laboratory 
worker  is  most  fortunate.     It  must  long  occupy  a  pre-eminent  position." 


THE  PRACTICE    OF  MEDICINE 


Anders* 
Practice   of  Medicine 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo,  1336  pages,  fully  illustrated.  Cloth,  ^5.50  net;  Half 
Morocco,  $7.00  net. 

JUST  OUT— THE  NEW  (IZth)  EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration  given 
to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of  distinction 
of  simulating  diseases  being  presented  in  tabular  form.  In  this  new  edition 
Dr.  Anders  has  included  all  the  most  important  advances  in  medicine,  keeping 
the  book  within  bounds  by  a  judicious  elimination  of  obsolete  matter.  A  great 
many  articles  have  also  been  rewritten. 

Wm,  E.  Quine,  M.  D., 

Professor  of  Medicine  attd  Clinical  Medicine,  College  of  Physicians  arid  Surgeons,  Chicago. 
"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession  at 
this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's   Physical   Diagtnosis 

Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  M.  D.,  Associate 
Professor  of  Medicine,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  557  pages,  with  225  original  illustrations.  Cloth,  $3.50  net. 

NEW  (2d)   EDITION 

Dr.  DaCosta' s  work  is  a  thoroughly  new  and  original  one.  Every  method 
given  has  been  carefully  tested  and  proved  of  value  by  the  author  himself. 
Normal  physical  signs  are  explained  in  detail  in  order  to  aid  the  diagnostician  in 
determining  the  abnormal.  Both  direct  and  differential  diagnosis  are  emphasized. 
The  cardinal  methods  of  examination  are  supplemented  by  full  descriptions  of 
technic  and  the  clinical  utility  of  certain  instrumental  means  of  research. 
Dr.   Henry  L.   Eisner,   Professor  of  Metlicine  at  Syracuse  University. 

•■  I  have  reviewed  this  book,  and  am  thoroughly  convinced  that  it  is  one  of  the  best  ever 
written  on  this  subject.     In  every  way  I  find  it  a  superior  production." 


SAUNDERS'   BOOK'S  ON 


Sahli*s  Diagnostic  Methods 


A  Treatise  on  Diagnostic  Methods  of  Examination.  By  Prof. 
Dr.  H.  Sahli,  of  Bern.  Edited,  with  additions,  by  Nath'l  Bowditch 
Potter.  M.  D.,  Assistant  Professor  of  Clinical  Medicine,  Columbia  Uni- 
versity (College  of  Physicians  and  Surgeons),  New  York.  Octavo  of 
1229  pages,  illustrated.     Cloth,  $6.50  net  ;   Half  Morocco,  $8.00  net. 

THE  NEW  (2d)  EDITION,  ENLARGED  AND  RESET 

Dr.  Sahli' s  great  work  is  a  practical  diagnosis,  written  and  edited  by  practical 
clinicians.  So  thorough  has  been  the  revision  for  this  edition  that  it  was  found 
necessary  practically  to  reset  the  entire  work.  Every  line  has  received  careful 
scrutiny,  adding  new  matter,  eliminating  the  old. 

Lewellys  F.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  Universitv 
"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in  the 
Johns  Hopkins  Medical  School." 

Friedenwald  and  Ruhrah  on  Diet 

Diet  in  Healtli  and  Disease.  By  Juliu.s  Friedenwald,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Pro- 
fessor of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.      Octavo  of  857  pages.  Cloth,  ;^4.oo  net. 

THE  NEW  (4th)  EDITION 

This  new  edition  has  been  carefully  revised,  making  it  still  more  useful  than  the  two 
editions  previously  exhausted.  The  articles  on  milk  and  alcohol  have  been  rewritten,  additions 
made  to  those  on  tuberculosis,  the  salt-free  diet,  and  rectal  feeding,  and  several  tables  added, 
including  Winton's,  showing  the  composition  of  diabetic  foods. 

George  Dock,  M.  D. 

Professor  of  Theory  and  Practice  and  of  Clinical  Medicine,    Tiilane   University. 
"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  available. 
I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  foods." 

Carter's  Diet  Lists 

Diet  Lists  of  the  Presbyterian  Hospital  of  New  York  City. 
Compiled,  with  notes,  by  Herbert  S.  Carter,  M.  D.  i2mo  of  129 
pages.  Cloth,  $1.00  net. 

Here  Dr.  Carter  has  compiled  all  the  diet  lists  for  the  various  diseases  and  for  conva- 
lescence as  prescribed  at  the  Presbyterian  Hospital.     Recipes  are  also  included. 


PRACTICE    OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and  Pancreas 

Diseases  of  the  Stomach,  Intestines,  and  Pancreas.  By  Robert 
Coleman  Kemp,  M.  D.,  Professor  of  Gastro-intestinal  Diseases  at  the 
New  York  School  of  Chnical  Medicine.  Octavo  of  102 1  pages,  with 
388  illustrations.     Cloth,  $6.z,o  net ;   Half  Morocco,  ;$8.oo  net. 

NEW  (2d)   EDITION 

The  new  edition  of  Dr.  Kemp's  successful  work  appears  after  a  most  search- 
ing revision.  Several  new  subjects  have  been  introduced,  notably  chapters  on 
Colo7i  Bacillus  Iifection  and  on  Diseases  of  the  Pancreas,  the  latter  article  being 
really  an  exhaustive  monograph,  covering  over  one  hundred  pages.  The  section 
on  Duodenal  Ulcer  has  been  entirely  rewritten.  Visceral  Displacements  are  given 
special  consideration,  in  every  case  giving  definite  indications  for  surgical  inter- 
vention when  deemed  advisable.  There  are  also  important  chapters  on  the  Intes- 
tinal Complications  of  Typhoid  Fever  and  on  Diverticulitis. 

The  Therapeutic  Gazette 

■'The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and  clinical 
examination  are  adequately  and  correctly  described." 


Gant  on  Diarrheas 

Diarrheal,  Inflammatory,  Obstructive,  and  Parasitic  Diseases  of 
the  Qa3tro=intestinal  Tract.     By  Samuel    G.   Gant,   M.  D.,  LL.D., 

Professor  of  Diseases  of  Sigmoid  Flexure,  Colon,  Rectum,  and  Anus, 
New  York  Post-graduate  Medical  School  and  Hospital.  Octavo  of  604 
pages,  181  illustrations.     Cloth,  $6.00  net;   Half  Morocco,  $7.50  net. 

JUST  OUT 

This  new  work  is  particularly  full  on  the  two  practical  phases  of  the  subject — 
diagnosis  and  treatment.  For  instance  :  While  the  essential  diagnostic  points  are 
given  under  each  disease,  a  fuller  description  of  diagnostic  methods  is  given  in  a 
special  chapter.  The  differential  diagnosis  of  diarrheas  of  local  and  those  of  sys- 
temic disturbances  is  strongly  brought  out.  There  is  a  special  chapter  on  ner- 
vous dia?-rheas  and  those  originating  from  gastrogenic  and  enterogenic  dyspepsias. 
You  get  methods  of  simultaneously  controlling  associated  constipation  and  diar- 
rhea. You  get  a  complete  formulary.  The  limitations  of  drugs  are  pointed  out, 
and  the  indications  and  technic  of  all  surgical  procedures  given. 

Gant  on  Constipation  and  Obstruction 

This  work  is  medical,  non-medical  (mechanical),  and  surgical,  the  latter  really 
being  a  complete  work  on  rectocolonic  surgery. 

Octavo  of  575  pages,  with  250  illustrations.     By  Samuel  G.  Gant,  M.  D.     Cloth,  $6.00  net. 


SAUNDERS'    BOOKS   ON 


NOTHNAGEL'S    PRACTICE 

Edited  by  ALFRED   STENGEL,  M.  D. 

Typhoid  and  Typhus  Fevers 

By  Dr.  H.  Curschmann.  Edited,  with  additions,  by  William  Osler,  M.  D;, 
F.  R.  C.  P.,  Oxford,  England.      Octavo  of  646  pages,  illustrated. 

Smallpox.  Varicella,  Cholera,  Erysipelas,  Pertussis,  Hay  Fever 

By  Dr.  H.  Immkrmann,  Dr.  Tu.  \()n  Jurgkxsen,  Dr.  C.  Lii:jii:rmkister, 
Dr.  H.  Lenhartz,  and  Dr.  G.  Sticker.  Edited,  with  additions,  by  Sir 
I.  W.  Moore,  I\T.  D.,  F.  R.  C.  P.  1.,  Ireland.    Octavo  of  682  pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  William  P.  Northrup,  M.  D.,  and  Dr.  Th.  von  Jurgensen.  Edited, 
with  additions,  by  William  P.  Northrup,  M.  D.,  New  York.  Octavo  of 
672  pages,  illustrated. 

Bronchi,  Pleura,  and  Inflammations  of  the  Lungs 

By  Dr.  F.  A.  Hoffalwx,  Dr.  ().  RosExiiACH,  and  Dr.  F.  Aufrecht. 
Edited,  with  additions,  Ijy  John  H.  Musser,  M.  D.      Octavo  of  1029  pages. 

Pancreas,  Suprarenals,  and  Liver 

By  Dr.  L.  Oser,  Dr.  E.  Neusser,  and  Drs.  H.  Quincke  and  G.  Hoppe- 
Sevler.  Edited,  with  additions,  by  Reginald  H.  Fitz,  M.  D.,  Boston; 
and  Fred.  A.  Packard,  M.  D.,  Phila.      Octavo  of  918  pages,  illustrated. 

Diseases  of  the  Stomach 

By  Dr.  F.  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles  G. 
Stockton,  M.  D.,  Buffalo.     Octavo  of  835  pages. 

Diseases  of  the  Intestines  and  Peritoneum  Second  Edition 

By  Dr.  Hermann  Nothnagel.  Edited,  with  additions,  by  H.  D.  Rolles- 
TON,  M.  D.,  F.  R.  C.  p.,  London.      Octavo  of  iioo  pages,  illustrated. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  Dr.  G.  Cornet.  Edited,  with  additions,  by  Walter  B.  James,  M.D., 
New  York.     Octavo  of  806  pages. 

Diseases  of  the  Blood 

By  Dr.  P.  Ehrlich,  Dr.  A.  Lazarus,  Dr.  K.  von  Noorden,  and  Dr. 
Felix  Pinkus.  Edited,  with  additions,  by  Alfred  Stengel,  M.  D.,  Phila- 
delphia.    Octavo  of  714  pages,  illustrated. 

Malarial  Diseases,  Influenza,  and  Dengue 

By  Dr.  J.  Mannaberg  and  Dr.  O.  Leichtenstern.  Edited,  with  additions, 
by  Ronald  Ross,  F.  R.  C.  S,;  J.  W.  W.  Stephens,  M.  D.;  and  Albert 
S.  Grunbaum,  F.  R.  C.  p.,  Liverpool.      Octavo  of  769  pages,  illustrated. 

Kidneys,  Spleen,  and  Hemorrhagic  Diatheses 

By  Dr.  H.  Senator  and  Dr.  M.  Litten.  Edited,  with  additions,  by  James 
B.  Herrick,  M.  D.,  Chicago.     Octavo  of  815  pages,  illustrated. 

Diseases  of  the  Heart 

By  Prof.  Dr.  Th.  von  Jurgen.sen,  Prof.  Dr.  L.  Krehl,  and  Prof.  Dr. 
L.  von  Schrotter.  Edited  by  George  Dock,  M.  D.,  New  Orleans.  Octavo 
of  848  pages,  illustrated. 

SOLD  SEPARATELY-PER    VOLUME:    CLOTH,  $5.00  NET;    HALF  MOROCCO,   $6.00   NET 


THERAPEUTICS  AND   EXERCISE  n 


Bastedo's   Materia    Medica 

Pharmacology,    Therapeutics,    Prescription    Writing 

Materia  Medica,  Pharmacology,  Therapeutics,  and  Prescription 
Writing.  By  W.  A.  Bastedo,  Ph.  D.,  M.  D.,  Associate  in  Pharma- 
cology and  Therapeutics  at  Columbia  University,  New  York.  Octavo 
of  602  pages,  illustrated.  Cloth,  $3.50  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Bastedo's  discussion  of  his  subject  is  very  complete.  As  an  illustration, 
take  the  pharmacologic  action  of  the  drug.  It  gives  you  the  antiseptic  action,  the 
local  action  on  the  skin,  mucous  membranes,  and  the  alimentary  tract  ;  where  the 
drug  is  obsorbed,  if  at  all — and  how  rapidly.  It  gives  you  the  systemic  action  on  the 
circulatory  organs,  respiratory  organs,  nervous  system,  and  sense  organs.  It  tells 
you  how  the  drug  is  changed  in  the  body.  It  gives  you  the  route  ol  elimination 
and  in  what  form.  It  gives  you  the  action  on  the  kidneys,  bladder,  urethra,  skin, 
bowels,  lungs,  and  mammary  glands  during  elimination.  It  gives  you  the  after- 
effects. It  gives  you  the  unexpected — the  unusual — effects.  It  gives  you  the 
tolerance — habit  formation.  Could  any  discussion  be  more  complete,  more 
thorough  ? 

Boston  Medical  and  Surgical  Journal 

"  Its  aim  throughout  is  therapeutic  and  practical,  rather  than  theoretic  and  pharmacolocric. 
The  te.xt  is  illustrated  with  sixty  well-chosen  plates  and  cuts.  It  should  prove  a  useful  con- 
tribution to  the  text-book  literature  on  these  subjects." 


McKenzie  on  Exercise  in 
Education    and    Medicine 

Exercise  in  Education  and  Medicine.  By  R.  Tait  McKenzie,  B.  A.^ 
M.  D.,  Professor  of  Physical  Education  and  Director  of  the  Department, 
University  of  Pennsylvania.  Octavo  of  585  pages,  with  478  original 
illustrations.  Cloth,  $4.00  net. 

D,  A.   Sargeant,   M.   D.,   Director  of  Hemenway  Gymnasium,  Harvard  Uni'^jersity. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of  an 
expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  praf'titioner." 

Bonney's  Tuberculosis  Second  Edition 

Tuberculosis.     By  Sherman  G.  Bonney,  M.  D.,  Professor  of  Medi- 
cine, Denver  and  Gross  College  of  Medicine.     Octavo  of  955  pages,  with 
243  illustrations.      Cloth,  $7.00  net ;   Half  Morocco,  |8. 50  net. 
Maryland  Medical  Journal 

"  Dr.  Bonney's  book  is  one  of  the  best  and  most  exact  works  on  tuberculosis,  in  all  its 
aspects,  that  has  yet  been  published." 


12  SAUNDERS'    BOOKS   ON 

Stevens'  Therapeutics  New  (sthj  Edition 

A  lEXT-liouR  ui-  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on  Physical  Diagnosis  in 
the  University  of  Pennsylvania.     Octavo  of  675  pages.     Cloth,  $3.50  net. 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the 
subject  ever  pubhshed.  In  this  new  edition  the  work  has  undergone  a 
very  thorough  revision,  and  now  represents  the  very  latest  advances. 

The  Medical  Record,  New  York 

"  Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Butler's  Materia  Medica  New  (6th)  Edition 

A  Text-Book  ov  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  .Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  $4.00  net;   Half  Morocco,  ^5.50  net. 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great 
part  having  been  rewritten.  All  obsolete  matter  has  been  eliminated,  and 
special  attention  has  been  given  to  the  toxicologic  and  therapeutic  effects 
of  the  newer  compounds. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the 
completeness  of  the  text." 

Sollmann's  Pharmacolog^y  New  (2d)  Edition 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D., 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Uni- 
versity.    Octavo  of  1070  pages,  illustrated.     Cloth,  $4.00  net. 

The  author  bases  the  study  of  therapeutics  on  systematic  knowledge  of 
the  nature  and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate 
relation  between  pharmacology  and  practical  medicine. 

Slade*s  Physical  Examination  and  Diagnostic  Anatomy 

Physical  Examination  and  Diagnostic  Anatomy.  By  Charles  B. 
Slade,  M.  D.,  Chief  of  Clinic  in  General  Medicine,  University  and 
Bellevue  Hospital   Medical   College.     Cloth,  $1.25  net. 

"  The  fundamental  methods  and  principles  of  physical  examinatioa,  well  illustrated,  largely  by  line 
drawings.     The  book  is  to  be  strongly  recommended." — Boston  Medical  and  Surgical  Journal. 

Amy's  Pharmacy 

Principles  of  Pharmacy.  By  Henry  V.  Arny,  Ph.  G.,  Ph.  D., 
Professor  of  Chemistry,  New  York  College  of  Pharmacy.  Octavo  of 
1 175  pages,  with  246  illustrations.      Cloth,  §5. 00  net. 


THERAPEUTICS  AND  MATERIA   MEDIC  A  13 


Tousey's  Medical  Electricity 
Rontgen  Rays,  ivnd  Radium 

Medical  Electricity,  Rontgen  Rays,  and  Radium.  By  Sinclair 
TousEY,  M.  D.,  Consulting  Surgeon  to  St.  Bartholomew's  Hospital, 
New  York.  Octavo  of  1219  pages,  with  801  illustrations,  19  in  colors. 
Cloth,  $7.50  net;   Half  Morocco,  $9.00  net. 

NEW  (2d)  EDITION,  RESET 

The  revision  for  this  edition  was  extremely  heavy  ;  new  matter  has  increased  the  size 
of  the  book  by  some  100  pages.  About  50  new  ilhistrations  have  been  added.  The  new 
matter  added  includes :  Diathermy,  sinusoidal  currents,  radiography  with  intensifvio" 
screens,  rontgenotherapy,  the  Coolidge  and  similar  Rontgen  tubes  and  the  author's  method 
of  dosage,  and  radium  therapy  are  noted.  The  book  has  been  enriched  by  including  several 
of  Machado's  tabular  classifications  of  electric  methods,  effects,  and  uses. 

Throughout  the  entire  work  everything  concerning  electricity,  x-rays,  and  radium  in 
medicine,  as  well  as  phototherapy,  is  explained  in  detail — nothing  is  omitted.  It  tells  you 
how  to  equip  your  office,  and,  more  than  that,  how  to  use  your  apparatus,  explaining  away 
all  difficulties.  It  tells  you  just  how  to  apply  these  measures  in  the  treatment  of  disease. 
The  chapters  on  dental  radiograpJiy  are  particularly  valuable  to  those  interested  in  dental 
work. 


Abbott's  Medical  Electricity  for  Nurses 

Medical  Electricity  for  Nurses.  By  Georl^e  Knapp  Abbott, 
M.  D.,  Dean  and  Professor  of  Physiologic  Therapy  and  Practice,  College 
of  Medical  Evangelists,  Loma  Linda,  California.  i2mo  of  132  pages, 
illustrated.  Cloth,  $1.25  net. 

This  new  work  gives  the  nurse  the  essentials  of  this  subject.  Dr.  Abbott's  style  has 
made  the  difficult  simple.      The  text  is  illustrated. 

Kelly's  American  Medical  Biography 

Cyclopedia  of  American  Medical  Biography.  By  Howard  A. 
Kelly,  M.  D.,  Johns  Hopkins  University.  Two  octavos,  averaging  525 
pages  each,  with  portraits.  Per  set :  Cloth,  $10.00  net;  Half  Morocco, 
$13.00  net. 

Dr.  Kelly,  in  these  two  handsome  volumes,  presents  concise,  yet  complete,  biog- 
raphies of  those  men  and  women  who  have  contributed  noteworthily  to  the  advance- 
ment of  medicine  in  America.  Dr.  Kelly's  reputation  for  painstaking  care  assures 
accuracy  of  statement.     There  are  about  one  thousand  biographies  included. 


14  SAUNDERS'    BOOK'S   ON 


GET  ML  •  THE  NEW 

THE  BEST  I\  III  6  IT  1  C  Si  li  STANDARD 

Illustrated    Dictionary 


Just  Out— New  (8th)  Edition— 1500  New  Words 

The  American  Illustrated  Medical  Dictionary By  W,  A.  New- 
man Borland,  M.  D.,  Editor  of  "The  American  Pocket  Medical  Dic- 
tionary." Large  octavo  of  11 37  pages,  bound  in  full  flexible  leather. 
Price,  ;^4.50  net;  with  thumb  index,  ^5.00  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

Howard  A.  Kelly ,M.D.,  P/v/essof  of  Gy?teco/o^ic  Surgery,  Johns  Hopkins  University. 

"  Dr.  Borland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose=Book.  New  (4th)  Edition 

Dose-Book  and  Manualof  Prescription-Writing.  By  E.  Q.  Thornton,  M.D., 
Assistant  Professor  of  Materia  Medica,  Jefferson  Medical  College,  Philadelphia.  Post- 
octavo,  410  pages,  illustrated.     Flexible  leather,  ^2.00  net. 

"  I  will  be  able  to  make  considerabla  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recom- 
mend the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text- 
books."— C.  H.  Miller,  "hi.  V>.,  Professor  of  Phar7nacology,Northiuestern  University  Medi- 
cal School. 

Lusk    on    Nutrition  New  (2d)   Edition 

Elements  of  the  Scunceof  Nutrition.  By  Graham  Lusk,  Ph.  D.,  Professor 
of  Physiology  in  Cornell  University  Medical  School.  Octavo  of  402  pages.  Cloth, 
;g3.oonet. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the  subject," 
— Lew^ellys  F.  Barker,  M.  T).,  Johns  Hopkins  University. 

Camac*s  "Epoch-marking  Contributions" 

Epoch-making  Contributions  in  Medicine  and  Surgery.  Collected  and 
arranged  by  C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages,  illus- 
trated.    Artistically  bound,  ^4.00  net. 

"  Dr.  Camac  has  provided  us  with  a  most  interesting  aggregation  of  classical  essays^ 
We  hope  that  members  of  the  profession  will  show  their  appreciation  of  his  endeavors." — 
1  herapeutic  Gazette. 


PRACTICE,    MATERIA   MEDIC  A,   Etc.  19 


The  American  Pocket  Medical  Dictionary  New  (9th)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman  Dor- 
LAND,  M.  D.,  Editor  '*  American  Illustrated  Medical  Dictionarv."  693  pages.  Flexible 
leatht^r,  with  gold  edges,  $1.00  net;   with  thumb  index,  $1.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

The  Practical  Application  of  the  Rontgkn  Rays  in  Therapeutics  and 
Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D.,  Professor  of  Dermatology  in 
the  University  of  Illinois;  and  EuGene  W.  Caldwell,  B.  S.,  Director  of  the  Edward 
N.  Gibbs  X-Ray  Memorial  Laboratory  of  the  University  and  Bellevue  Hospital  Medical 
College,  New  York.  Octavo  of  eas'pnges,  with  200  illustrations.  Cloth,  I5.00  net; 
Half  Morocco,  $6.50  net. 

Cohen   and    Eshner's    Diagnosis.      Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshner,  M.  D., 
Professor  of  Clinical   Medicine,  Philadelphia  Polyclinic.      Post-octavo,  382  pages  ;  55 

illustrations.      Cloth,  ^l. 00  net.     In  Saunders'  Question-Compend  Sei-ies. 

Morris'  Materia  Medica  and  Therapeutics.  New  (7th)  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics.  Jefferson  Medical 
College,  Phila.  Revised  by  W.  A.  Bastedo,  M.  D.,  Instructor  in  Materia  Medica  and 
Pharmacology  at  Columbia  University.  1 2mo,  300  pages.  Cloth,  ^i. 00  net.  In  Saunders' 
Question-  Conipend  Series. 

Williams'  Practice  of  Medicine 

Essentials  of  the  Practice  of  Medicine.  By  W.  R.  W'illiams,  M.D., 
formerly  Instructor  in  Medicine  and  Lecturer  on  Hygiene,  Cornell  University  ;  and 
Tutor  in  Therapeutics,  Columbia  L^niversity,  N.  Y.  l2mo  of  456  pages,  illustrated. 
In  Saunders''  Question-Conipe^td  Series.     Double  number,  $1.75  net. 

Todd's  Clinical  Diagnosis  The  New  (3d)  Edition 

A  Manual  of  Clinical  Diagnosis.  By  James  Campbell  Todd,  M.D.,  Professor 
of  Pathology,  University  of  Colorado.  l2rao  of  585  pages,  with  164  text-illustrations 
and  10  colored  plates.     Cloth,  %z.'^o  net. 

Bridge  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge.  A.  M.,  M.  D.,  Emeritus  Professor  of  Medicine 
in  Rush  Medical  College.     i2mo  of  302  pages,  illustrated.     Cloth,  ^1.50  net. 

Oertel  on  Bright' s  Disease  illustrated 

The  Anatomic  Histological  Processes  of  Bright's  Disease.  By  Horst 
Oertel,  M.  D,  Director  of  the  Russell  Sage  Insdtute  of  Pathology,  New  York.  Octavo 
of  227  pages,  with  44  text-cuts  and  6  colored  plates.     Cloth,  $5.00  net. 

Arnold's  Medical  Diet  Charts 

Medical  Diet  Charts.  Prepared  by  H.  D.  Arnold,  M.  D.,  Dean  of  Harvard 
Graduate  Medical  School,  Boston.  Single  charts,  5  cents;  50  charts,  $2.00  net  ;  300 
charts,  |lS.oo  net ;    1000  charts,  $30.00  net. 

Eggleston's  Prescription  Writing 

ESSENTIALS  OF  PRESCRIPTION  WRITING.  Bv  CarY  Eggleston,  M.  D.  Instructor 
in  Pharmacology.  Cornell  University  Medical  School.  i6mo  of  125  pages.  Cloth.  $1.00 
net. 


1 6  SAUNDERS'    BOOKS    ON  PRACTICE,   Etc. 

Jakob  and  Cshner's  Internal  Medicine  and  Diagnosis 

Atlas  AND  Eitiomk  ok  Internal  Mkdicine  and  Clinical  Jjia(;n().sis.  By  Dr. 
Chk.  Jakoh,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  Eshner,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  1S2  colored  figures  on 
68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth,  ^3.00  net.  In  Saunders' 
Hand-Atlas  Series. 

Lockwood's  Practice  of  Medicine.  „  Second  Edition. 

Revised  and  Cnlar{(ed 

A  Manual  ok  the  Practice  ok  Medicine.  By  Geo.  Roe  LocKwt)OD,  M.  D., 
Attending  Physician  to  the  Bellevue  Hospital,  New  York  City.  Octavo,  847  pages* 
with  79  illustrations  in  the  text  and  22  full-page  plates.      Cloth, '^4.00  net. 

Stevens*  Practice   of  Medicine  just  Out— New  (lothj  Edition 

A   Manual  ok  the  Practice  ok  Medicine.     By  A.  A.  Stevens,  A.  M.,  M.  D., 

Professor   of    Pathology,    Woman's    Medical    College,    Phila.  Specially    intended   for 

students  preparing  for  graduation  anil    hospital  examinations.  Post-octavo,  629  pages, 
illustrated.      Flexible  leather,  $2.50   net, 

Saunders*  Pocket  Formulary  New  (9th)  Edition 

Sai'Nders'  Pocket  Medical  Formulary.  By  William  M.  Powell,  M.  D. 
Containing  1S31  formulas  from  the  best-known  authorities.  With  an  Appendix  con- 
taining Posologic  Table,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons  and 
their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal  Head,  Obstetrical  Table, 
Diet-list,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from 
Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc., 
etc.     In  flexible  leather,  with  side  index,  wallet,  and  flap,  ^1.75  net. 

De&derick  on  Malaria 

Practical  Study  ok  Malaria.  By  William  H.  Deaderick,  M.  D.,  Member 
American  Society  of  Tropical  Medicine;  Fellow  London  Society  of  Tropical  Medicine 
and  Hygiene.  Octavo  of  402  pages,  illustrated.  Cloth,  $4.50  net;  Half  Morocco, 
$6.00  net. 

Niles  on  Pellagra 

Pellagra.  By  George  M.  Nii.es,  M.  D.,  Professor  of  Gastro-enterology  and 
Therapeutics,  Atlanta  School   of  Medicine.      Octavo   of  253  pages,  illustrated.     Cloth, 

;S3.oo  net. 

Hinsdale's  Hydrotherapy 

Hydrotherapy.  By  Guy  Hinsdale,  M.  D.,  Fellow  Royal  Society  of  Medicine 
of  Great  Britain.      Octavo  of  466  pages,  illustrated.     Cloth,  ^3.50  net. 

Swan's  Prescription-writing  and  Formulary 

Prescription-writing  and  Formulary.  By  John  M.  Swan,  M.  D.,  formerly 
Director  Glen  Springs  Sanitarium,  Watkins,  N.  Y.  l6mo  of  185  pages.  Flexible 
leather,  ^1.25  net. 


Stewart's  Pocket  Therapeutics  and  Dose-book 


Fourth 
Edition 

Pocket  Therapeutics  and  Dose-Book.     By  Morse  Stewart,  Jr.,  M.  D.     32mo 
of  263  pages.     Cloth,  ^i.oo  net. 


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